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MEDICAL    GYNECOLOGY 


A   TEEATISE   ON   THE    DISEASES   OF   WOMEN   FROM 
THE   STANDPOINT   OF  THE  PHYSICIAN 


BY 

ALEXANDER  J.   C.  ^KENE,  M.  D. 

PROFESSOR  OF   GYNECOLOGY   IN   THE   LONG   ISLAND   COLLEGE   HOSPITAL,    BROOKLYN,    NEW   YORK 

FORMERLY     PROFESSOR     OF     GYNECOLOGY     IN     THE     NEW    YORK     POST-GRADUATE     MEDICAL     SCHOOL 

GYNECOLOGIST   TO   THE    LONG   ISLAND   COLLEGE   HOSPITAL 

PRESIDENT    OF    THE    AMERICAN    GYNECOLOGICAL    SOCIETY,    1887 

CORRESPONDING   MEMBER   OF  THE   BRITISH,  BOSTON,  AND    DETROIT   GYNECOLOGICAL   SOCIETIES 

OP    THE    ROYAL    SOCIETY    OF    MEDICAL   AND    NATURAL    SCIENCES    OF    BRUSSELS 

OF   THE   PARIS    OBSTETRICAL   SOCIETY 

AND   OF   THE   LEIPZIG   OBSTETRICAL   SOCIETY 

FELLOW    OF  THE   NEW   YORK   ACADEMY   OF   MEDICINE 

EX-PRESIDENT   OF   THE   MEDICAL   SOCIETY   OF   THE   COUNTY    OF   KINGS 

EX-PRESIDENT   OF   THE   NEW   YORK   OBSTETRICAL    SOCIETY 


WITH  ILLUSTRATIONS 


NEW    YORK 

D.    APPLETON    AND    COMPANY 

1895 


SklL 


Copyright,  1894, 
By  D.  APPLETON  AND  COMPANY. 


PREFACE. 


The  growth  of  gynecology  in  recent  times  has  been  phe- 
nomenal, especially  in  the  direction  of  surgery.  That  in  this 
respect  its  progress  should  have  been  remarkable  is  not  sur- 
prising, in  view  of  the  great  advances  made  in  general  sur- 
gical knowledge  during  that  period. 

It  appears  in  medical  literature  that  surgery  has  been 
more  assiduously  cultivated  than  medicine.  This  may  have 
induced  some  to  push  the  surgical  treatment  of  diseases  of 
women  to  extremes,  and  in  some  degree  to  neglect  medicine. 
On  the  other  hand,  physicians,  who  have  been  overconfident 
in  their  art,  may  have  failed  occasionally  to  do  surgery  full 
Justice.  This  is  evidently  responsible  for  the  frequent  and 
often  illogical  discussions  which  have  been  going  on  in  the 
past  few  years  regarding  so-called  radical  and  conservative 
practice  in  gynecology. 

The  science  and  art  of  medicine  and  surgery  in  their 
highest  development  should  be  above  all  party  questions, 
and  those  who  place  a  Just  estimate  on  both  branches  of  the 
healing  art,  and  employ  them  without  predilection  and 
prejudice,  are  the  most  successful  and  reliable.  Unreason- 
able devotion  to  either  medicine  or  surgery  is  wrong. 

A  consciousness  on  the  part  of  the  author  of  this  status 
of  gynecology  is  responsible  for  the  inception  and  genesis  of 
this  work.  How  far  he  may  be  right  in  thinking  that  there 
is  room  for  a  new  work  on  the  medical  branch  of  gynecology, 
and  to  what  extent  the  requirements  have  been  met  in  this 
volume,  the  members  of  the  medical  profession  alone  can 
decide. 


iy  MEDICAL   GYNECOLOGY. 

The  popularity  of  tlie  author's  contributions  to  gyneco- 
logical surgery  in  the  past  raises  the  hope  that  this  work  may 
meet  with  an  equally  favorable  reception. 

The  volume  is  arranged  in  three  parts  : 

Part  I.  deals  with  the  primary  differentiation  of  sex,  de- 
velopment and  growth  during  early  life,  and  the  conditions 
favorable  to  the  evolution  of  normal  organization  and  the 
attainment  of  a  healthful  puberty.  This  involves  the  discus- 
sion of  heredity  and  environment,  including  care  in  child- 
hood, mental  and  physical  education  and  culture,  together 
with  the  necessary  attentions  during  the  transition  from  girl- 
hood to  womanhood. 

Part  II.  treats  of  the  characteristics  of  sex,  the  adaptation 
of  structure  to  function,  the  predisposition  to  particular  dis- 
eases, and  the  causes  of  certain  affections  j)eculiar  to  women. 
Then  follow  all  the  functional  and  organic  diseases  common 
to  the  period  of  active  functional  life  of  woman  which  natu- 
rally come  under  the  observation  and  care  of  the  physician. 

Part  III.  discusses  the  menopause,  or  the  transition  from 
active  functional  life  toward  advanced  years,  and  then  the 
diseases  of  the  latter  period. 

The  great  object  in  the  first  part  of  this  work  is  to  con- 
sider as  fully  as  possible  the  ways  and  means  of  developing 
vigorous  organizations  and  maintaining  healthy  functional 
life.  This  necessitates  attention  to  hygiene  at  all  periods  of 
life,  and  all  that  the  term  implies. 

In  discussing  the  treatment  of  diseases  the  author  has 
endeavored  to  define,  as  clearly  as  possible,  the  boundary 
lines  between  medicine  and  surgery,  and  their  capabilities, 
so  that  each  may  be  thoroughly  understood  and  employed 
for  the  relief  of  suffering  and  the  saving  of  life. 

The  Author. 


TABLE    OF    CONTENTS. 


CHAPTER 


PAGE 

I. — Primary  Differentiation  of  Sex 1 

II. — Secondary  Differentiation  of  Sex        ...        .        .        .        .16 

III. — Menstruation 35 

IV.— Derangements  of  Menstruation  (General  Maldevelopment)   .  43 
V, — Sexual    Characteristics:    Structural   Differences   between 

THE  Sexes 61 

VI. — General  Functional  Characteristics  of  the  Sexes  ...  79 

VII. — Woman's  Function  in  Life 84 

VIII. — Natural  and  Sexual  Selection 93 

IX. — Peculiarities   in   the   Diseases    of   Women   growing   out   of 

Sexual  Characteristics 97 

X. — General  Therapeutic  Agents   employed   in  the   Practice  of 

Gynecology 100 

XL — General  Consideration  of  Electricity  in  the  Therapeutics 

OF  Gynecology 107 

XII. — Muscular  Exercise,  Massage,  and  Diet  in  Disease  .        .        .  137 

XIII. — Mental  Therapeutics  and  Institutional  Treatment         .        .  148 

XIV. — Methods  of  Examining  Patients 159 

XV. — Derangements   of   Menstruation   due  to   Certain  Affections 

OF  THE  Nutritive  System 171 

XVI. — Derangements  of  the  Sexual  Function 189 

XVII. — Acute  Inflammatory  Affections  of  the  Pelvic  Organs  .        .  199 
XVIII. — Chronic  Inflammation  of  the  Pelvic  Organs     .        .        .        .311 
XIX. — Chronic    Inflammation    of    the    Pelvic    Organs    {continued). 

Chronic  Ovaritis  and  Salpingitis 380 

XX. — Displacements  of  the  Uterus 834 

XXL — Constitutional    Derangements    due   to  or  accompanying    In- 
flammatory Diseases  of  the   Sexual   Organs,  and  their 

Treatment 349 

XXII. — Diseases  of  the  External  Genitals 355 

XXIII. — Functional  Diseases  op  the  Nervous  System  associated  with 

Diseases  op  the  Sexual  Organs 874 

XXIV.— Hysteria .  385 


vi  MEDICAL  GYNECOLOGY. 

CHAPTER                                                                                                                                                                        -  PAGE 

XXY.— Neurasthexia 304 

XXVI.— Sex  and  its  Relations  to  Insanity 315 

XXVII. — Affections  of  the  Mammary  Glands 348 

XXVIII.— The  Uterine  Fibromata .        .358 

XXIX.— Cancer 362 

XXX.— Unnatural  Habits 369 

XXXI. — Diseases  of  the  Urinary  Organs 378 

XXXII. — Diseases  of  the  Bladder  and  Urethra.     Functional  Dis- 
eases OF  THE  Bladder 384 

XXXIII. — Functional  Diseases  of  the  Bladder  caused  by  Certain  Af- 
fections OF  the  General  Nervous  System  ....  399 
XXXIV. — Functional   Derangements   of  the   Urinary  Organs  caused 

BY  Diseases  of  other  Pelvic  Organs 424 

XXXV. — Organic  Diseases  of  the  Bladder 434 

XXXVI.— Cystitis 441 

XXXVII. — Functional  Diseases  of  the  Urethra 463 

XXXVIII. — The   Transition  from   Middle   Life   to  Old  Age,  and  the 

Diseases  of  that  Period.    The  Menopause        .        .        .  468 

XXXIX.— Diseases  of  Old  Age 480 

XL. — Senile  Endometritis 489 

XLI. — Prolapsus  of  the  Abdominal  Viscera  and  Pelvic  Organs    .  505 

XLII. — Varicose  Veins  of  the  Pelvis 511 


MEDICAL   GYNECOLOGY. 


PAKT   I. 


CHAPTER  I. 

PEIMAEY   DIFFEEENTIATION   OF   SEX. 

The  union,  in  utero^  of  paternal  and  maternal  cells  forms 
the  germ  of  the  future  being.  There  are  elements  from 
which  the  general  organization  is  formed,  and  those  which 
are  detailed  to  form  the  organs  of  reproduction. 

Each  germ  contains  two  sets  of  elements — the  one  endowed 
with  the  power  to  evolve  a  human  being  and  designed  from 
the  first  for  that  purpose,  the  other  destined  to  develop  the 
organs  for  future  reproduction. 

The  germ  of  the  embryo  is  said  to  contain  the  elements  of 
both  sexes,  but  almost  immediately  a  sex  is  determined  by 
certain  factors  assuming  prominence  and  activity,  while 
others  remain  stationary,  finally  to  undergo  atrophy. 

Primary  differentiation  of  sex  is  guided  by  the  condition 
of  the  parents  at  the  time  of  generation  and  the  nature  of  the 
germ. 

As  animate  things  naturally  assume  the  characteristics  of 
the  seed  from  whence  they  spring,  the  primary  differentiation 
of  sex  is  influenced  by  heredity,  which,  in  fact,  is  in  force  to 
the  highest  degree  during  the  development  of  sex,  and  is  the 
chief  factor  in  causing  the  primary  character istics  of  sex — 
i.  e.,  the  sexual  organs.  At  birth  the  primary  differentiation 
of  sex  is  completed,  or  nearly  so,  and  thus  far  the  process  is 
under  the  law  of  heredity. 


2  MEDICAL   GYNECOLOGY. 

Not  only  is  the  specific  object  of  these  organs  indicated, 
but  the  ultimate  sexuality  is  in  all  respects  advancing  to  com- 
pletion. 

At  birth  the  sexual  organs  of  the  female  child  are  formed, 
and,  with  the  exception  of  the  uterus,  have  attained  their  char- 
acteristic shape  and  outline,  but  they  are,  of  course,  immature 
in  size.  The  general  organization  has,  too,  certain  indica- 
tions of  sex,  although  these  are  not  well  marked. 

Sexual  differences  become  more  apparent  as  the  animal 
rises  in  the  zoological  scale,  and  in  the  human  race  the  repro- 
ductive organs  are  the  last  to  complete  their  development.  It 
is  not  until  general  bodily  perfection  is  nearly  attained  that 
the  sexual  organs  undergo  secondary  development.  It  is  now 
that  the  general  sexual  characteristics  of  the  body  and  mind 
are  shown  in  the  mysterious  transformation  which  occurs  at 
this  period  of  life. 

At  puberty  the  organism,  then  complete,  is  capable  of  re- 
production, one  of  the  chief  offices  of  living  beings.  From 
birth  until  puberty  all  functions  save  the  sexual  are  identical 
in  kind,  if  not  in  degree,  with  those  performed  during  the 
time  of  reproductive  life.  When  the  time  called  puberty 
arrives  the  complex  series  of  events  denominated  sexual  make 
themselves  manifest,  usually  in  a  well-recognized  way,  and  it 
is  then  that  the  organs  of  the  general  system  and  the  sexual 
system,  though  anatomically  different,  become  functionally 
correlated.  The  functions  of  ovulation  and  menstruation  are 
assumed.  It  is  during  the  period  of  development  that  the 
physician  has  the  best  opportunity  to  render  his  most  valu- 
able services  to  the  race,  therefore  it  is  in  order  here  to  con- 
sider all  questions  pertaining  to  the  management  of  girls 
from  childhood  to  puberty. 

HYGIENE,   CLOTHING,   FOOD,   AND  ENVIRONMENT  DURING 

EARLY   LIFE. 

A  most  important  and  much  neglected  subject  bearing 
upon  this  time  of  woman's  life  is  that  concerning  her  food, 
clothing,  exercise,  education,  and  environment  generally. 


PRIMARY  DIFFERENTIATION  OF  SEX.  3 

To  begin  life  well  one  must  be  born  of  parents  wlio  are 
sound  in  body  and  mind.  They  need  not  be  educated,  ac- 
cording to  the  popular  meaning  of  that  term.  Size  and  vigor 
of  brain  and  body  are  transmitted  according  to  purely  phys- 
ical laws.  The  children  of  well-developed,  healthy  parents 
who  may  have  but  a  limited  school  education  often  possess 
great  mental  ability,  while,  on  the  other  hand,  the  children 
of  great  geniuses  are  often  stupid.  The  brains  of  great  men 
and  women  are  often  ruined  by  their  excessive  and  ill-directed 
labor,  and  their  children  inherit  this  wreckage,  not  the  origi- 
nal excellence.  So,  also,  the  athlete  may  injure  his  body 
and  transmit  his  broken  health  to  his  children.  It  is  not 
what  people  have  been,  or  what  they  hope  to  be,  but  what 
they  are  at  the  time  they  generate,  that  is  transmitted  to 
their  progeny.  The  characteristics  of  parents  come  down  to 
their  children  under  laws  beyond  control  of  the  will. 

Medical  science  is,  to  some  extent,  powerless  in  the  face  of 
heredity.  Because  of  imperfect  mental  and  physical  health, 
certain  men  and  women  are  unfit  to  procreate  ;  but  the  advice 
of  the  physician  is  seldom  asked  for  on  this  subject,  nor  is  it 
always  accepted  when  offered. 

Science  demands  that  none  but  the  healthy  should  have 
offspring  ;  but  the  social  state  ignores  the  demand.  The  laws 
which  protect  the  lives  and  property  of  the  present  generation 
can  only  be  operative  for  the  interest  of  future  generations ; 
so  the  best  that  can  be  done  is  to  improve  and  keep  in  health 
those  who  are  to  be  the  parents  of  the  coming  generation. 

And  the  multitudinous  nineteenth-century  resources  and 
devices — alimentation,  physical  culture,  change  in  climate,  in 
nurses,  in  the  possession  and  constant  following  of  the  physi- 
cian's directions  in  all  the  undertakings  of  physical  and  men- 
tal life — often  seem  to  me  pretty  nearly  equal  in  final  results 
to  healthy  parentage. 

After  birth  and  throughout  childhood  the  influence  of 
parents  may  tend  to  make  children  like  themselves,  or  to 
make  them  better  or  worse  than  themselves,  according  to  the 
kind  of  care  and  culture  bestowed. 


4  MEDICAL   GYNECOLOGY. 

Food  is  tlie  primary  necessity  in  raising  children  ;  the 
character,  quantity,  and  time  of  administration  should  each 
have  the  scrupulous  attention  of  all  those  who  are  responsible 
for  the  welfare  of  children.  There  is  only  one  reliable  source 
of  supply  for  an  infant.  It  is  the  first  "food  for  infants" 
used,  and  it  has  not  yet  been  equaled  by  any  other.  It  is, 
indeed,  a  sad  sight  to  see  a  helpless  infant  cut  off  from  the 
maternal  supply  of  food  and  forced  to  depend  upon  stuff 
manufactured  by  those  guided  in  their  work  by  a  formula 
they  do  not  understand  and  hence  can  not  imitate.  If  a 
mother,  by  any  misfortune  or  physical  defect,  is  unable  to 
care  for  her  own  young,  a  nurse  should,  if  possible,  be  pro- 
vided. It  is  a  great  misfortune  to  begin  life  with  artificial 
food.  The  poor  usually  do  right  by  their  infants  so  far  as 
feeding  them  for  the  first  year  is  concerned;  but  in  this 
country  the  rich  are  often  derelict  in  this  respect.  It  is  a  fact 
that  a  great  many  wealthy  mothers  can  not  nurse  their  own 
children.  Dr.  George  M.  Beard,  who  had  much  of  the  real 
scientist  in  him,  once  asked  me  what  proportion  of  educated 
women  of  the  better  class  were  able  to  nurse  their  children. 
I  could  not  tell  him  then,  but  I  have  since  made  observations 
which  show  that  the  proportion  is  small — far  smaller  than  it 
should  be  ;  smaller  than  among  the  poor,  who  are  in  less  fa- 
vorable circumstances.  Many  there  are  who  are  too  weak  to 
perform  that  most  important  of  duties ;  some  there  are  who 
will  not. 

It  is  essential  to  have  the  maternal  affection  well  devel- 
oped. The  hand  seldom  errs,  either  in  controlling  or  caress- 
ing, when  guided  by  pure  and  intelligent  affection.  Still, 
affection  not  under  the  guidance  of  reason  and  intelligence 
often  leads  to  grave  mismanagement.  Love  for  children, 
with  a  clear  appreciation  of  one's  duty  toward  them,  and 
knowledge  of  the  methods  of  caring  for  them,  are  all  neces- 
sary to  success. 

The  love  of  children  should  not  be  so  blind  and  all-absorb- 
ing as  to  exclude  justice  and  common  sense.  This  leads  to 
unwise  indulgence,  which  is  ruinous.     The  want  of  love  for 


PRIMARY   DIFFERENTIATION   OP   SEX.  5 

children  leads  to  neglect,  with  consequences  which,  though 
differing  from  overindulgence,  are  equally  unfavorable.  The 
lower  animals  care  for  their  young  in  a  most  rational  and 
effective  manner.  They  protect  them  with  wonderful  saga- 
city, but  do  not  spoil  them  with  overindulgence.  They  feed 
them  in  accordance  with  the  most  approved  fare,  guard  them 
from  danger,  teach  them  all  they  have  to  impart,  and  bring 
them  to  maturity  well  prepared  for  the  life  they  have  before 
them.  Here  is  to  be  found  in  a  humble  way  the  most  per- 
fect example  of  caring  for  the  young.  The  whole  process  is 
conducted  upon  a  plane  far  below  that  of  the  human  family, 
but  it  is  perfect  as  far  as  it  goes.  The  highest  illustration  of 
the  proper  care  of  children  is  to  be  found  in  parents  who 
have  a  full  share  of  love  for  children  which  gives  interest, 
and  also  a  clear  comprehension  of  how  to  manage  them,  both 
with  regard  to  what  they  need  and  how  to  bestow  it.  The 
two  extremes  may  be  called  the  upper  and  lower  boundaries 
of  the  proper  training  of  the  young.  Between  these  all  kinds 
of  imperfections  and  blunderings  are  to  be  found. 

In  all  this  training  and  education  the  mother  is  the  chief 
actor.  Nearly  all  the  duties  devolve  upon  her.  The  father 
can  help  by  his  counsel  and  support,  and  when  boys  are 
nearing  manhood  he  can  help  them,  and  from  that  time  on- 
w^ard,  but  this  is  about  all  he  can  do.  Occasionally  a  mother 
is  found  so  inefficient  that  the  father  must  needs  take  the 
larger  share  in  caring  for  the  children  ;  but  he  usually  makes 
poor  work  of  it. 

Overdevotion  to  children  on  the  part  of  the  mother  is  to 
be  carefully  guarded  against.  Though  in  a  given  case  the 
children  are  not  injured,  but  fortunately  and  wisely  cared 
for  by  all  this  observing  care,  still  no  mother  should  give  her 
whole  life  to  her  children  unless  she  is  left  alone  with  them. 
In  the  complete  household  there  are  others  who  require  her 
care  and  attention  besides  the  young  autocrats  of  the  home 
circle. 

The  quantity  of  food  given  should  be  limited  only  by  the 
wants  of  the  child.     When  a  child  is  in  health  the  appetite  is 


6  MEDICAL  GYNECOLOGY. 

the  best  guide  in  feeding  it,  so  far  as  regards  quantity.  Sins 
without  number  have  been  committed  in  scrimping  the  diet 
of  girls  in  order  to  make  them  delicate,  believing  that  to  be 
sickly  and  helpless  is  to  be  ladylike.  Strange  it  is  that  some 
women  who  talk  the  loudest  about  woman's  rights  deny  their 
own  girls  (I  should  say  girl,  as  they  usually  have  but  one) 
the  right  to  eat  enough  to  satisfy  hunger.  Children  seldom 
overeat  unless  the  wicked  habit  of  making  too  long  an  inter- 
val between  meals  is  established.  Dr.  A.  Jacobi  says  children 
not  only  eat  to  live,  but  eat  to  grow  also. 

Nutritive  changes  in  childhood  are  so  rapid  and  the  de- 
mands so  frequent  that  the  quantity  of  food  required  is  rela- 
tively greater  than  in  adult  life ;  hence  children  should  be 
fed  at  regular  and  rather  frequent  intervals. 

Want  of  attention  to  this  induces  the  bad  habit  of  eating 
scraps  between  meals.  If  the  time  is  not  too  long,  children 
seldom  ask  for  food  in  the  intervals.  These  general  statements 
suffice  for  all  healthy  children,  and  therefore  special  care  is 
necessary  only  when  in  given  cases  there  is  some  ajiparent 
malnutrition.  When  any  derangement  occurs  in  the  primary 
processes  of  nutrition  it  is  usually  manifested  by  loss  of  ap- 
petite or  irregularity  and  capriciousness  in  the  desire  for  food. 
On  the  other  hand,  when  the  secondary  processes — i.  e.,  assim- 
ilation (or  the  appropriation  of  nutriment  by  the  tissues  of 
the  body)  and  metabolism— are  deranged,  the  result  will  ap- 
pear in  the  character  of  the  tissues.  Examples  of  this  are 
seen  in  children  that  are  fat  and  pale-faced.  They  are  often 
regarded  as  pictures  of  health  by  the  laity,  while  to  the  phy- 
sician they  are  simply  evidences  of  malassimilation.  Their 
food  literally  runs  to  fat  in  place  of  bone,  nerve,  and  muscle. 
The  object,  then,  should  be,  when  catering  for  the  one  class, 
to  find  food  that  agrees  with  the  stomach,  which  really  means 
food  which  that  particular  stomach  can  digest.  In  the  other 
class  that  food  should  be  used  which  gives  the  kind  of  tissue 
most  needed.  In  all  cases  it  is  safe  to  employ  an  abundant 
supply  which  includes  both  animal  and  vegetable  food,  and 
the  variety  should  only  be  limited  by  the  exclusion  of  articles 


PRIMARY  DIFFERENTIATION  OF   SEX.  Y 

which  are  known  to  be  unwholesome.  Finally,  girls  and  boys 
should  eat  at  the  same  table  and  fare  alike.  The  differen- 
tiation of  sex  which  is  observed  at  birth  should  remain  ele- 
mentary until  toward  puberty,  so  that  during  childhood  the 
nutrition  of  both  sexes  should  be  the  same.  But  the  food 
and  feeding  of  girls  about  the  time  of  puberty  is  a  subject  of 
much  magnitude.  I  presuppose  the  fact  that  the  general 
principles  of  dieting  are  known,  and  I  shall  specially  consider 
the  subject  in  reference  to  the  physical  culture  of  girls. 

In  the  first  place,  I  am  perfectly  satisfied  that  a  mixed 
diet  is  necessary  to  all,  that  is,  it  should  include  animal  and 
vegetable  articles  of  food,  and  in  quantity  snfiicient  to  satisfy 
the  wants.  There  is,  of  course,  much  difference  in  the  kind 
of  food  required  by  each  girl.  One  who  is  healthy,  actively 
occupied,  and  growing  requires  as  much  food  as  an  adult ; 
many  seem  to  want  even  more.  They  should  partake  of  at 
least  three  good  meals  a  day  and  have  ample  time  for  masti- 
cation and  insalivation  as  well  as  for  subsequent  digestion. 

It  frequently  happens  that  it  is  beneficial  for  girls  to  eat 
oftener  than  thrice  a  day,  the  amount  in  such  cases  being  less 
than  if  the  regulation  number  of  meals  were  taken. 

Too  little  attention  is  given  in  this  country  to  the  subject 
of  food  and  feeding. 

Eating  should  become  an  essential  and  pleasant  duty,  to 
be  at  all  times  enjoyed — first  a  duty,  and  then  an  agreeable 
and  pleasant  pastime.  A  young  growing  girl  who  does  not 
enjoy  her  breakfast  is  not  at  all  likely  to  enjoy  her  school 
work  ;  indeed,  a  girl  should  not  be  permitted  to  go  to  school 
if  she  has  not  eaten  a  good  and  sufiicient  breakfast.  If  an 
engineer  and  his  locomotive  should  come  up  and  report  for 
duty  in  the  morning  without  a  tender,  both  would  be  sent 
back  as  unfit  for  the  work  before  them.  The  same  should 
apply  exactly  to  schoolgirls.  A  good,  nutritious,  easily  di- 
gested lunch  should  be  eaten  by  all  schoolgirls.  While  am- 
bitious scholars  may  struggle  along  without  proper  food  for  a 
time,  they  are  sure  to  break  down  in  time.  Another  error  is 
hurried  eating ;   this  impairs  the  appetite  and  causes  it  to 


8  MEDICAL  GYNECOLOGY. 

flag.  Too  highly  seasoned  food  will  develop  a  morbid  appe- 
tite, and  eating  such  should  be  forbidden  before  digestion  is 
completely  ruined. 

The  question  here  arises  as  to  what  should  be  given  to 
drink.  Certainly  in  this  country  there  is  too  much  water 
drinking,  and  the  unwise  custom  of  partaking  of  tea, 
coffee,  wine,  mineral  w^aters,  and  fancy  drinks  known  under 
the  generic  term  of  soda  water.  This  climate  with  its  ex- 
treme summer  heat  is,  no  doubt,  largely  responsible  for  this 
unfortunate  habit,  but  deranged  digestion  from  improper 
feeding  is  also  an  important  cause.  It  may  be  laid  down  as 
a  rule  that  the  great  American  drink — iced  water — should 
not  be  indulged  in  immediately  before,  during,  or  immediate- 
ly after  meals.  K  thirst  demands  it,  a  little  iced  water  may  be 
slowly  taken  from  an  hour  to  half  an  hour  before  meals,  or 
time  enough  to  allow  the  stomach  to  fully  recover  from  the 
chilling  process,  and  it  should  not  be  taken  again  until  long 
enough  after  meals  to  allow  gastric  digestion  to  be  pretty 
nearly  completed.  Warm  drinks  are  less  objectionable,  and 
that  raises  the  question  as  to  whether  children  should  be 
allowed  tea,  coffee,  cocoa,  and  the  like.  I  believe  that  any  of 
these  may  be  given  in  small  quantity  w^hen  largely  diluted 
and  made  agreeable.  I  believe  it  is  the  best  w^ay  of  supply- 
ing the  fluid  necessary  to  insure  digestion.  This,  I  think,  is 
particularly  essential  at  breakfast  time  in  this  trying  climate. 
For  luncheon  at  school,  tea  and  coffee  may  be  withheld,  and 
the  necessary  fluid  supplied  in  the  form  of  soup  or  bouillon. 
At  the  evening  meal  most  children  do  better  w^ithout  either 
tea  or  coffee  ;  but  if  a  natural  thirst— one  not  acquii^ed  by 
habit— demands  drink,  pure  water,  Apollinaris,  Hygeia,  or 
some  of  the  table  waters  that  are  known  to  be  pure  may  be 
indulged  in. 

All  that  has  been  said  on  this  subject  applies  to  the 
healthy,  strong,  well-balanced  organization — to  those  who  by 
reason  of  good  health  are  capable  of  digesting  wholesome 
food  and  who  do  not  require  any  special  kind  of  diet  because 
of  some  defect  in  their  health  or  general  organization. 


PRIMARY  DIFFERENTIATION  OF  SEX.  9 

We  now  come  to  the  most  important  part  of  this  subject, 
and  that  is  the  management  of  unhealthy  girls.  And  first  of 
all,  because  most  frequently  seen  in  this  country,  is  the 
spare,  nervous  girl  with  a  capricious  appetite — one  who  sel- 
dom if  ever  has  a  good  appetite  for  breakfast.  At  times  such 
a  one  will  eat  enough,  perhaps  more  than  seems  necessary, 
while  again  she  declines  all  food.  With  such  it  is  very  neces- 
sary that  they  should  have  perhaps  a  still  greater  variety, 
always  keeping  within  the  bounds  of  wholesome  food,  and  yet 
such,  as  it' were,  that  invites  them  to  eat.  They  certainly  are 
benefited  by  partaking  of  some  warm  drink,  like  weak  tea  or 
coffee,  the  first  thing  in  the  morning. 

I  have  found  very  weak  coffee  with  a  little  lemon  Juice 
and  sugar  to  provoke  an  appetite  for  breakfast  in  very  deli- 
cate individuals,  and  to  take  away  the  desire  for  drinking 
more  coffee  or  anything  else  after  eating.  Should  this  fail  to 
induce  an  appetite,  let  them  drink  a  cup  of  good  cocoa  ;  this 
is  nutritious  and  disliked  by  few. 

If  they  can  partake  of  solid  food,  warm  milk,  eggs,  and 
oatmeal  with  cream  and  sugar  form  an  excellent  breakfast. 
At  times  a  small  piece  of  bacon  or  smoked  beef,  well  cooked 
and  presented  in  a  delicate  way,  acts  as  an  appetizer.  Should 
any  or  all  of  these  succeed  in  whetting  the  appetite,  there 
must  nevertheless  be  an  alternation  of  them  from  time  to 
time,  for  the  appetite  is  a  nervous  function  and  soon  grows 
intolerant  of  routine. 

I  exclude  from  the  diet  of  this  class  of  cases  hot  bread, 
cakes,  fried  potatoes,  sausages,  and  salt  fish,  except  carefully 
prepared  codfish  balls. 

It  is  a  mooted  question  how  much  animal  food  girls  of  this 
temperament  should  partake  of.  Once  a  day  is  often  enough, 
I  believe. 

Sweets — ice-cream  and  sweet  desserts — are  both  enjoyable 
and  profitable  in  these  cases  ;  but  pastry  never.  And  I  be- 
lieve that  food  denominated  "fatty"  can  be  taken  with  ad- 
vantage. 

I  have  been  describing  the  modus  mvendi  of  that  tempera- 


10  MEDICAL  GYNECOLOGY. 

ment  wMch  modern  science  aptly  calls  '•'■  sensiUf^''''  or  ''^  sensi- 
tif-actif^^ — temperaments  (formerly  nervous)  whose  fancy, 
imagination,  introspection,  ambition,  strong  passions,  and  ex- 
cessive sensibilities,  with  marked  physical  activity  (nervous 
strength),  are  the  prominent  features. 

The  phlegmatic  type  of  former  years  we  now  know  as 
'•'- apatliique^'' — heavy,  stolid,  slow,  sleepy,  lazy — yet,  strange 
to  say,  with  at  times  such  characteristics  of  the  ''''  sensitif^'' 
class  that  we  may  well  call  them  ^^ sensitif-apatJiique.'^'' 

These  girls  require  a  very  different  diet.  They  should 
have  very  little  farinaceous  food,  very  little  sugar,  but  a  saf- 
ficient  supply  of  lean  meat,  brown  bread,  oatmeal,  fruit,  and 
the  less  starchy  vegetables.  Barley  flour,  which  contains  less 
starch  than  the  average  farinaceous  articles  of  food,  is  of  the 
greatest  advantage  to  them,  and  can  be  cooked  in  a  variety  of 
ways,  both  agreeable  and  beneficial.  A  limited  supj)ly  of 
fluids  should  be  partaken  of,  whereas  girls  of  the  sensitif 
(nervous)  type  should  be  encouraged  to  the  ingestion  of  larger 
quantities. 

Pure  aJ}' is  high  on  the  list  of  those  conditions  that  may  be 
called  essential  elements  of  growth,  development,  and  health. 
This  all-important  factor  in  life  and  the  maintenance  of 
health,  a  constant  supply  of  which  we  all  know  is  mandatory, 
is,  at  least  in  large  cities,  nearly  always  contaminated,  and 
yet  with  a  little  attention  much  of  the  bad  air  which  we  are 
obliged  to  breathe,  as  things  now  are,  may  be  avoided.  As  our 
houses  are  built  (and  schoolhouses  are  included),  the  air  is  often 
very  contaminated,  and  it  is  impossible,  by  any  effort  on  the  part 
of  the  housekeeper  or  teacher,  to  have  it  at  all  times  what  it 
should  be.  Great  attention,  however,  should  be  given  to  this, 
and,  if  it  is  impossible  to  secure  the  requisite  supply  of  fresh 
air  in  school,  children  should  be  kept  in  the  open  air  the 
larger  portion  of  their  time.  The  sleeping  rooms  of  growing 
girls  can  nearly  always  be  ventilated ;  and  if  a  little  atten- 
tion is  given  to  selecting  schools,  much  can  be  done,  and  with 
the  additional  advantage,  that  as  soon  as  the  teachers,  espe- 
cially of  the  private  and  higher  schools,  know  that  the  parents 


PRIMARY   DIFFERENTIATION   OF  SEX.  H 

and  guardians  insist  on  good  ventilation,  they  will  make 
efforts  to  secure  it. 

Parlors  and  sitting  rooms  should  in  winter  be  carefully 
ventilated,  or  children  and  young  girls  should  be  kept  out  of 
them.  My  idea  is  that  after  each  recitation  of  an  hour  in 
school  the  children  should  go  out  for  a  five  or  ten  minutes' 
run.  More  out-of-door  life  is  necessary,  and  none  the  less  so 
because  our  climate  seems  against  it. 

In  connection  with  the  subject  of  pure  air  it  is,  of  course, 
needless  to''  say  that  the  plumbing  should  be  perfect  in  all 
buildings. 

Predisposition  to  disease  is  often  transmitted,  but  also 
arises  from  malenvironment  in  early  life.  Impure  air  is  said 
to  predispose  to  phthisis  by  preventing  development  oi  lung 
tissue,  thus  giving  the  bacilli  of  tubercle  a  fair  field  to  act  in. 

Chlorosis  is  in  part  induced  by  impure  air  and  inaction  of 
the  respiratory  organs  in  early  life.  And  since  chlorotics  are 
prone  to  degenerative  diseases  and  cancer,  the  effects  of  im- 
pure air  are  often  far-reaching  in  their  evil  influence. 

While  in  adult  life  the  results  of  breathing  impure  air 
are  visible  and  immediate,  such  is  not  the  case  to  the  same 
extent  in  youth.  But  the  results  are  just  as  bad  and  more 
lasting. 

Clothing  has  for  its  object  the  securing,  as  far  as  possible, 
of  warmth — an  equable  temperature — to  the  body.  While 
it  is  a  protection,  it  should  never  retard  motion.  Clothing 
should  be  equally  distributed  over  the  body,  and  there  is  no 
reason  why  the  chest  and  abdomen  of  a  child  should  be  cov- 
ered thickly  and  with  finery  while  the  arms  and  legs  are  as 
bare  as  a  savage's.  During  the  transition  from  girlhood  to 
womanhood  marked  attention  is  necessary,  with  special  refer- 
ence to  the  characteristics  and  peculiarities  of  sex.  I  may 
allude  here  to  certain  respects  in  which  errors  are  most  likely 
to  occur  in  regard  to  clothing.  At  the  present  time,  and  prob- 
ably in  the  past,  fashion  seems  to  be  based  upon  capricious 
ideas.  While  it  should  be  governed  entirely  by  the  la,ws  of 
adornment,  which  play  an  important  part  in  sexual  selection 


12  MEDICAL  GYNECOLOGY. 

of  the  female,  it  is  in  reality  governed  by  perverted  ideas  of 
what  is  supposed  to  be  beautiful  and  attractive.  About  the 
time  when  this  transition  takes  place  the  usual  custom  is  to 
increase  the  weight  of  skirts  and  to  use  corsets,  intending 
thereby  to  beautify.  This  Avould  be  all  perfectly  right  if  it 
did  not  interfere  with  health.  There  is  that  in  the  mental 
condition  of  girls  and  mothers  which  prompts  them  to  seek 
the  robes  of  maturity,  but  it  is  contrary  to  hygiene  to  add 
additional  weight  to  the  skirts  and  to  induce  severe  constric- 
tion at  the  waist  by  tight  clothing,  which  is  usually  emiDloyed 
at  this  period  of  life.  Corsets^the  subject  of  condemnation 
by  all  reformers  in  dress — are  still  worn  by  women,  and  it  is 
possible  that  they  ever  will  be.  Their  persistent  use  has  led 
me  to  study  the  subject.  I  have  come  to  the  conclusion  that 
this  injurious  article  of  the  wardrobe  is  not  so  very  bad  in 
itself.  Corsets,  if  properly  made  and  worn  as  they  ought  to 
be,  are  as  harmless  as  any  portion  of  clothing  usually  worn. 
It  is  the  abuse  of  the  article  that  we  condemn.  The  corset 
has  been  so  long  worn  that  there  is  a  demand  established  for 
it,  and  the  mammary  glands  of  civilized  women  require  sup- 
port because  the  deep  fascia — the  natural  support  of  these 
glands — is  imperfectly  developed,  and  has  been  so  for  many 
generations,  this  imperfection  having  been  transmitted  from 
mother  to  daughter  through  heredity.  The  resulting  pendu- 
lous state  of  the  breasts  therefore  requires  artificial  support, 
and  this  is  best  suj)plied  by  well-fitting  corsets.  This  has 
been  overlooked  by  those  who  would  institute  immediate 
reform,  entirely  abandoning  this  article  of  clothing.  It  would 
take  several  generations  to  cultivate  a  form  and  figure  that 
would  admit  the  disuse  of  corsets  in  mature  womanhood. 
Take  the  women  of  our  own  time  as  they  are,  and  it  will  be 
found  that  they  are  more  comfortable  and  just  as  healthy 
with  the  proper  use  of  corsets.  The  absurd  and  cruel  habit 
of  lacing  corsets  need  not  be  alluded  to,  except  to  say  that 
there  is  this  great  danger  not  generally  known  even  to  those 
who  desire  to  dress  rationally :  that  the  waist  will  contract 
under  very  slight  but  long-continued  pressure.     The  corset 


PRIMARY   DIFFERENTIATION    OF  SEX.  13 

that  is  only  snug  to-day  will  be  loose  a  week  hence.  The 
same  harm  can  be  done  by  wearing  a  tight  waist.  Great  care 
should  therefore  be  exercised  in  keeping  corsets  loose,  espe- 
cially in  young  growing  women.  I  have  also  thought  that  if 
some  elastic  material  could  be  introduced  into  the  mechanism 
of  the  corset  which  would  permit  every  motion  of  the  body, 
at  the  same  time  giving  required  support  to  the  mammary 
glands  and  to  the  skirts,  it  would  be  an  improvement ;  in 
fact,  I  believe  such  a  corset  is  now  obtainable. 

I  do  not  find  it  possible  to  separate  the  discussion  of  the 
harm  done  by  corset  wearing  about  the  time  of  puberty  and 
that  occurring  to  the  mature  woman  in  the  active  period  of 
her  life. 

Tight  corsets  induce  costal  respiration,  and  our  anatomies 
and  physiologies  calmly  tell  us  that  this  is  the  feminine  type. 
But  a  woman  whose  waist  is  nonconstricted  will  breathe  like 
a  healthy  man. 

The  pelvic  circulation  is  greatly  dependent  upon  the  free 
movement  of  the  diaphragm  ;  hence  anything  tight  about  the 
lower  ribs  works  positive  harm  to  the  sexual  organs. 

This  is  scarcely  the  place  to  adduce  all  the  displacements 
of  uterus,  liver,  stomach,  kidneys,  or  intestines  that  are  re- 
corded and  described  as  direct  results  of  tight  lacing  from 
corsets,  straps,  or  belts.  To  the  anatomist  they  form  a  cham- 
ber of  horrors. 

The  outline  of  woman  is  rendered  inartistic  and  sometimes 
monstrous.  The  thoracic  cavity  and  the  abdominal  cavity 
attain  shapes  most  disadvantageous  to  health,  beauty,  func- 
tion, or  life. 

Women  who  lace  rather  tightly  have  a  protuberant  abdo- 
men projecting  beyond  the  vertical  line  of  the  bust ;  this  is 
physiologically  and  artistically  bad. 

Pressure  around  the  waist  tends  to  develop  a  thick  layer 
of  adipose  tissue  in  the  abdominal  wall  below  it ;  hence  the 
very  woman  who  does  not  want  a  TiigTi  stomach  induces  one. 

Constrictions  around  the  waist  bulge  downward  the  pelvic 
floor,  the  result  of  the  unyielding,  unnatural  wall  above  it. 


14  MEDICAL   GYXECOLOGY. 

Dr.  R.  L.  Dickenson  found  prolapsus  uteri  in  etiery  case 
where  there  was  evidence  of  tight  lacing.  Of  course  the  pro- 
lapsus was  not  always  extensive ;  but  what  a  percentage ! 
Anteflexion,  retroversion — perhaps  every  variety  of  uterine, 
malposition — have  over  and  over  again  been  induced  by  waist 
constriction. 

Perhaps  no  organ  is  influenced  more  by  waist  constriction 
than  the  one  that  contains  one  quarter  of  all  the  blood  in  the 
body ;  and  when  we  recollect  that  at  the  important  time  of 
puberty  this  great  organ  may  weigh  twice  as  mucTi — in  pro- 
portion to  the  body  weight — as  in  the  middle  of  woman's 
active  life,  the  immense  damage  of  tight  lacing  in  girlhood 
can  be  estimated  by  any  one. 

The  great  writers  on  the  liver  (Frerichs  and  Murchison) 
describe  the  diseases  and  displacements  arising  from  tight 
pressure  about  the  liver  region. 

The  position  of  the  stomach  may  be  so  changed — and  that 
of  the  pancreas  with  it — that  dyspej)sia  may  appear  early  in 
life,  to  remain  incurable  and  permanent.  I  shall  soon  refer 
to  physical  culture  in  women,  and  it  only  remains  to  be  said 
that  free  movement,  free  breathing,  and  all  capacity  for  good, 
moderate  exercise  out  of  doors  or  in  a  gymnasium,  are  im- 
possible with  even  moderate  tight  lacing. 

So  much  of  good  development  depends  on  easy  and  free 
locomotion  that  the  greatest  attention  must  be  paid  to  the  fit 
and  flexibility  of  the  shoes.  It  is  only  during  the  forming 
stage  of  life  that  bodily  perfection  may  be  obtained.  After 
maturity,  should  a  woman  enjoy  squeezing  her  feet  she  is  free 
to  do  so ;  but  children  should  have  shoes  to  protect,  not  to 
deform  their  feet.  High  heels  have  spoiled  the  utility  and 
beauty  of  thousands  of  limbs  otherwise  beautiful  and  natural. 

After  the  matter  of  clothing  comes  the  next  most  impor- 
tant hygienic  measure,  and  that  is  that  more  time  should  be 
given  to  rest  and  healthful  physical  exercise,  so  that  the  ad- 
ditional tax  added  to  the  nutritive  system  of  developing  the 
sexual  organs  should  be  obtained.  Too  long  confinement  in 
the  sitting  and  stooping  position  in  school,  standing  in  an 


PRIMARY  DIFFERENTIATION  OF  SEX.  15 

awkward  position  during  the  recitations,  extra  hours  of  study 
out  of  school  time  at  home,  in  which  the  same  unfavorable 
attitudes  to  development  and  growth  are  maintained,  should 
be  most  carefully  avoided  during  this  transition  period  in  the 
development. 

Dr.  Mosher  *  gave  the  results  of  extensive  and  careful  ob- 
servations in  regard  to  asymmetry  of  the  body  produced  dur- 
ing girlhood  by  unnatural  positions  in  sitting  and  standing 
at  home  and  in  school.  She  pointed  out  well-marked  irregu- 
larities of  the  face,  showing  the  deviation  of  the  nose  to  one 
side,  want  of  symmetry  between  the  eyes  and  the  angles  of 
the  mouth,  and  a  corresponding  deformity  was  noticed  in  the 
pelvic  organs,  the  uterus  inclining  a  little  to  one  side  of  the 
pelvis,  that  side  to  which  it  inclined  being  determined  by  the 
habitual  attitude  of  the  girl  in  standing  or  sitting.  These 
deviations,  while  slight  in  the  great  majority  of  cases,  were 
in  others  exceedingly  well  marked. 

Since  my  attention  was  directed  to  this  through  Dr.  Mosher 
I  have  satisfied  myself  by  observation  that  these  deviations 
from  symmetrical  formation  are  most  likely  to  be  brought 
about  during  the  two  years  preceding  puberty,  though  no 
doubt  they  are  begun  earlier  in  life.  These  points  that  I 
have  simply  hinted  at  will  be  referred  to  again  while  consid- 
ering the  irregularities  of  development  specially  manifested 
in  the  sexual  organs,  and  due  largely  to  irrational  education 
and  deranged  conditions  of  early  life. 

*  Paper  read  before  the  Kings  County  Medical  Society. 


CHAPTER  n. 

SECOTTDARY   DIFFERENTIATION   OF   SEX  AT   PUBERTY. 

The  physical  and  mental  characteristics  of  sex  evolved  at 
this  period  of  secondary  development  will  be  discussed  far- 
ther on  in  the  chapter  devoted  to  the  anatomical  and  physio- 
logical peculiarities  of  women.  In  this  connection  attention 
will  be  confined  to  the  influences  and  conditions  which  effect 
this  stage  of  development,  and  the  sj)ecial  care  and  attention 
necessary  at  puberty. 

The  influence  of  the  reproductive  system  in  guiding  the 
development  of  the  being  toward  certain  attainments  peculiar 
to  the  sex  doubtless  begins  during  embryonic  life,  but  it  is 
when  puberty  comes  that  the  effect  is  most  apparent ;  and 
secondary  characteristics  of  sex  result  from  many  influences, 
the  chief  of  which  is  the  existence  of  the  sexual  organs  and 
their  relation  to  the  general  organization. 

Since  heredity  and  environment  are  also  potent  factors, 
physical  and  mental  culture  should  appeal  to  them  to  find 
conditions  necessary  to  attain  normal  development,  and  the 
therapeutic  management  of  malformations,  deranged  func- 
tions, and  many  of  the  diseases  of  women  should  be  directed 
by  light  from  the  same  source. 

During  early  youth,  probably  until  the  twelfth  year,  the 
characteristics  of  the  female  sex  are  gradually  evolved  under 
the  influence  of  the  sexual  organs.  This  is  assumed  first 
upon  the  negative  evidence  obtained  from  the  fact  that  there 
is  nothing  yet  discovered  in  the  structure  and  functions  of 
the  general  system  of  the  two  sexes  to  produce  the  differen- 
tiating characteristics  of  sex.     The  mental  and  physical  i^e- 

16 


SECONDARY  DIFFERENTIATION  OF  SEX  AT   PUBERTY.        17 

culiarities  of  sex  appear  in  early  life  to  a  limited  degree, 
while  the  sexual  organs  are  still  imperfectly  developed  and 
functionally  inactive.  It  is  toward  puberty,  when  the  organs 
are  undergoing  secondary  development,  that  their  influence  is 
exercised  in  the  highest  degree.  In  fact,  the  reciprocal  effects 
of  the  two  systems  upon  each  other  are  quite  apparent  at  that 
time.  If  at  puberty  a  girl  is  defective  in  her  general  struc- 
ture, the  sexual  organs  often  fail  to  be  perfectly  formed  ;  and 
even  when  the  general  system  is  well  developed,  should  the 
sexual  organs  be  defective,  the  whole  organization  is  modified. 
A  number  of  cases  might  be  quoted  to  illustrate  this  point, 
but  it  is  enough  to  say  that  when  the  sexual  organs,  especially 
the  ovaries,  are  congenitally  absent,  the  subject  will  fail  to 
develop  the  attributes  and  general  appearances  of  the  female 
sex.  In  such  cases  the  tendency  is  toward  the  masculine 
type  of  the  species.  One  such  person  I  have  seen.  She  had 
the  narrow  pelvis,  square  shoulders,  rudimentary  mammary 
glands,  full  beard,  and  hairy  body — in  a  word,  the  body  of  a 
male.  Such  subjects  show,  better  than  any  discussion  can, 
the  effect  which  the  sexual  organs  have  upon  the  physical 
development  of  woman,  and  also  that  the  tendency  of  devel- 
opment is  toward  the  less  complex  organization  of  the  species 
when  freed  from  the  influence  of  the  sexual  system.  The 
question  naturally  arises  whether  the  product  of  such  a  de- 
velopment is  the  result  of  the  absence  of  sexual  organs,  or  is 
due  to  some  peculiarity  of  the  whole  organization  which  had 
its  origin  in  some  deviation  from  health  in  the  germinal 
cell.  This  latter  cause,  of  course,  is  possible  but  not  very 
probable,  because  if  the  deviation  from  the  normal  fe- 
male type  were  due  to  disease  of  the  primary  element  or 
elements,  deformity  would  be  more  likely  to  occur  than  a 
change  from  one  normal  type  to  another.  Were  it  necessary 
to  quote  authorities  to  sustain  this  point  a  great  many  could 
be  given. 

One  or  two  will  suffice :  Yirchow  states  that  all  the  specific 
properties  of  woman's  body  and  mind,  all  her  nutritive  and 
nervous  sensibilities,  the  delicacy  and  roundness  of  her  figure. 


18  MEDICAL  GYNECOLOGY. 

and  in  fact  all  her  womanly  characteristics,  depend  npon  her 
ovaries. 

This  expresses  the  opinion  of  the  majority  of  those  who 
think  upon  the  subject,  and  I  can  see  no  other  way  by  which 
such  results  could  be  obtained  except  through  influences  ex- 
erted during  development. 

The  dex)endence  of  sexual  dimorphism  is  well  shown  by 
Prof.  Max  Weber,  of  Amsterdam.*  He  presents  the  case  of 
a  chaffinch  in  which  the  left  side  of  the  body  had  the  female 
coloration  and  the  right  that  of  the  male  bird,  the  middle  line 
sharply  defining  them.  The  bird  was  a  hermaphrodite  with 
a  well-developed  ovary  in  that  side  of  the  body  clothed  in 
female  jDlumage,  and  a  testicle  on  the  opposite  side. 

Dr.  Bertkanf  describes  an  insect  with  the  coloration  of 
the  wings  male  on  one  side  and  female  on  the  other.  Dissec- 
tion of  it  showed  degeneration  of  the  sexual  organs.  The 
directing  and  ever-acting  influence  of  the  ovaries  is  thus 
shown  to  be  exercised  throughout  the  animal  world ;  and 
when  this  activity  manifests  itself  for  the  first  time — when 
menstruation  occurs — puberty  is  established. 

Special  attention  must  be  given  to  the  physical  wants 
of  girls  at  puberty.  Much  of  the  information  regarding 
what  they  are  to  expect  and  how  to  protect  themselves 
then  must  come  from  the  mother  or  a  cultivated  woman  of 
mature  years  and  good  judgment.  Up  to  the  time  preceding 
the  first  menstruation  a  gii'l  should  be  left  in  ignorance  of 
her  sexual  organs  and  all  that  pertains  to  them.  But  when 
the  important  time  arrives  she  should  report  to  mother  or 
governess  the  occurrence  of  the  event ;  and  even  then  many 
things  need  not  be  told  until,  later,  she  is  to  assume  other 
and  higher  social  relations. 

At  the  first  appearance  of  the  flow  the  girl  must  be  pro- 
tected from  sudden  changes  of  temperature,  exposure  to  cold 
or  to  exhausting  heat,  sea  voyages,  change  in  climate  (save 
from  an  unfavorable  to  a  favorable  spot),  extreme  nervous 

*  Proceedings  of  the  Zoological  Society,  1873,  p.  241. 
f  Arehiv  fiir  Xaturgeschichte,  iv,  p.  75. 


SECONDARY   DIFFERENTIATION  OF  SEX  AT   PUBERTY.        19 

excitement  (either  pleasant  or  unpleasant),  extreme  muscular 
exertion,  exposure  to  contagion  of  any  sort,  and  from  any 
indiscretion  in  diet  that  could  eventuate  in  indigestion. 

The  overfed,  sluggish  girl,  raised  among  great  comforts — 
she  v^ho  belongs  to  the  class  of  apathiques — should  exer- 
cise ;  but  the  bookv^orm — the  sensitif — should  go  to  the 
fields  for  fresh  air,  sunlight,  and  mild  exercise.  An  over- 
v^orked  girl  v^ho  is  an  actif  in  temperament  needs  rest  espe- 
cially. 

DisregaTd  at  puberty  of  these  rules  is  capable  of  arresting 
the  evolution  of  the  sexual  organs,  deranging  their  functions 
and  impairing  their  future  health  and  usefulness. 

When  girls  arrive  at  the  time  when  general  development 
is  near  completion  it  is  absolutely  necessary  that  the  repro- 
ductive organs  should  take  up  their  functions  promptly  and 
perfectly.  According  to  the  observations  of  Dr.  Emmet, 
more  than  half  of  all  women  who  at  puberty  suffered  from 
menstrual  derangements  are  sterile  and  delicate  in  after-life. 
This  shows  how  important  it  is  to  begin  right.  My  own  ob- 
servations show  that  the  vast  majority  of  incurable  diseases 
peculiar  to  women  originate  in  imperfect  development  and 
the  consequent  derangement  of  function.  The  best  organiza- 
tions possess  greatest  power  to  resist,  and  although  they  are 
still  liable  to  diseases  and  accidents,  they  possess  a  strong 
tendency  to  recuperate  and  respond  more  promptly  to  the 
care  of  the  physician  and  surgeon  than  those  who  begin 
wrong. 

The  physical  conditions  necessary  to  meet  the  demands 
of  the  reproductive  system,  are  the  conditions  which,  in  their 
integrity,  are  best  adapted  not  only  to  maintain  health,  but 
also  to  resist  the  causes  of  disease,  whether  they  are  intrinsic, 
extrinsic,  or  reflex. 

PHYSICAL  CULTURE. 

The  most  important  function  of  the  physician  relates  to 
the  development  of  the  young  and  growing,  and  to  the  pre- 
vention of  disease.     I   therefore   consider  that  a  work  on 


20  MEDICAL  GYNECOLOGY. 

hygiene  and  therapeutics  would  lack  an  important  feature  if 
this  subject  were  not  discussed. 

Much  has  been  said  and  written,  but  without  much  foun- 
dation and  fact,  about  the  delicate  health  of  American  women. 
The  statement  that  there  is  an  apparent  degeneration  of  the 
Avomen  in  this  country  is  founded  on  no  better  basis  than  that 
some  women  and  girls  of  this  country  are  in  ill  health,  but 
delicate  and  sickly  people  are  found  everywhere.  Were  we 
to  measure  health  and  strength  by  mental  and  physical  labor 
accomplished,  the  women  of  America  would  compare  very 
favorably  with  those  of  other  lands.  It  must  be  conceded, 
however,  that  much  of  the  suffering  and  sickness  which  pre- 
vails at  the  present  time  might  be  prevented  if  more  intelli- 
gent care  were  given  to  the  physical  culture  and  development 
of  the  young.  This  subject  includes  all  that  relates  to  the 
develojDment  and  hygiene  of  body  and  mind  ;  but  I  shall  limit 
my  remarks  in  this  connection  more  especially  to  that  which 
relates  to  physical  culture  generally.  The  great  object  is  to 
develop  the  whole  body  evenly  and  consistently,  wdth  a  view 
of  adaptation  to  the  requirements  of  mature  life.  Those  who 
have  given  most  attention  to  physical  culture,  whose  opinions 
and  judgment  are  most  fully  in  harmony  with  the  facts  ob- 
served in  the  practice  of  medicine,  inform  us  that  the  condi- 
tions and  training  which  best  develojD  the  general  organiza- 
tion are  most  favorable  to  the  development  of  the  brain  and 
nervous  system  and  of  the  sexual  system  also. 

Imperfect  development  arises  in  many  ways.  In  one  large 
class  there  are  many  defects  of  organization  and  consequent 
imperfect  functions  and  ill  health  which  come  fi^om  the 
neglect  or  want  of  any  systematic  physical  education.  The 
poorer  classes  are  by  misfortune  compelled  to  violate  all  or 
most  of  the  rules  of  hygiene,  and  they  lack  wholly  physical 
culture.  Unfortunately,  it  also  happens  that  those  who  are 
so  circumstanced  as  to  possess  the  means  to  obtain  all  required 
education  and  culture  suffer  because  of  uneven  development. 
This  simply  means  that  one  portion  of  the  organization  is  de- 
veloped at  the  expense  of  the  other,  and  hence  we  find  those 


SECONDARY  DIFFERENTIATION  OF  SEX  AT  PUBERTY.   21 

who  are  weak  in  certain  directions  while  they  may  be  com- 
paratively strong  in  others.  There  is  that  lack  of  harmony 
which  characterizes  a  perfect  development  in  which  the  whole 
body,  brain  included,  is  adapted  to  the  requirements  or  duties 
of  the  individual. 

It  is  a  well-established  fact  that  a  full  development  not 
only  of  the  nutritive  and  nervous  systems,  but  also  of  the 
sexual  organs,  is  necessary  to  the  fulfillment  of  the  functions, 
and  consequently  to  the  general  mental  and  physical  well- 
being  of  women.  The  hygiene  of  the  reproductive  organs 
during  girlhood  is  not  alone  sufficient,  because  these  organs 
depend  upon  the  nutritive  system  for  nearly  all  the  conditions 
of  their  growth,  develoj)ment,  and  maintenance,  and  hence 
the  highest  organic  perfection  of  the  sex  can  only  be  obtained 
indirectly  through  the  general  system.  It  follows,  therefore, 
that  a  perfect  system  of  general  physical  culture  and  hygiene 
will  cover  the  ground  pertaining  to  physical  culture  and  care 
during  early  life.  It  would  be  beyond  the  capacity  of  this 
work  to  give  here  the  general  laws  of  hygiene  so  far  as  they 
are  known  and  taught.  They  are  to  a  great  extent  alike 
adapted  to  the  young  of  both  sexes.  It  will  suffice  to  state 
that  all  those  conditions  which  secure  the  highest  type  of 
physical  womanhood  are  also  most  favorable  to  the  develop- 
ment of  the  peculiarities  of  sex  and  the  best  system  of  hy- 
giene and  culture  of  the  present  day.  There  are  rules  suffi- 
cient for  the  care  of  girls,  generally,  but  there  are  many  fluc- 
tuating opinions  among  authorities  regarding  the  laws  of 
health  as  applied  to  the  female  sex  in  reference  to  some  of 
the  peculiarities  of  organization  which  should  be  here  noted. 
Many  of  the  defects  come  from  mistaken  views  respecting 
what  constitutes  true  culture.  In  the  present  state  of  society 
in  this  country  too  much  time  is  devoted  by  one  class  to 
mental  culture  and  too  much  by  another  to  the  struggle  for 
existence.  Nearly  all  our  institutions  of  learning  are  devoted 
to  mental  training  and  moral  culture,  while  there  are  no  or- 
ganized means  of  physical  culture  except  gymnasiums,  where 
excessive   and   spasmodic   muscular   exercise  passes  current 


22  MEDICAL  GYNECOLOGY. 

oftentimes  as  physical  education.  It  seems  as  if  tlie  culture 
of  the  nervous  and  muscular  systems  comprised  the  whole 
subject  of  education. 

There  is  another  false  principle  which  prevails  to  a  great 
extent  in  those  systems — namely,  the  ap]olication  of  one 
course  to  every  variety  of  subjects.  The  precocious  dyspep- 
tic girl — the  girl  who  belongs  to  the  sensitif  or  actif-sensitif 
type — pursues  the  same  course  of  training  as  the  one  who  is 
mentally  dull  but  physically  vigorous— the  apatJdque  or  ac- 
tif.  Now,  as  the  object  of  all  true  culture  is  to  secure,  as 
far  as  possible  in  every  way,  the  development  of  body  and 
mind,  it  follows  that  the  method  employed  should  be  adapted 
to  the  special  qualities  of  each  individual :  in  one  the  intel- 
lect requires  most  attention,  while  digestion  and  assimilation 
ought  to  be  cultivated  in  another.  In  place  of  one  general 
course  for  all,  a  custom  prevailing  to-day,  there  should  be  a 
special  course  for  each,  according  to  the  requirements  of  her 
organization.  As  society  is  organized  in  the  j)resent  age  it 
is  impossible  to  follow  out  this  plan,  but  more  and  stronger 
efforts  should  be  made  toward  improving  and  perfecting  it. 
The  medical  profession  could  do  much  to  disseminate  needed 
information  on  the  subject.  The  confidence  which  is  inspired 
by  the  belief  in  the  progress  of  medicine  in  the  departments 
of  hygiene  and  preventive  medicine  gives  hope  for  more 
rational  culture  in  the  future.  Physicians  ought  to  be  at  all 
times  ready  to  give  advice  to  and  prescribe  for  those  who  are 
undergoing  physical  culture  and  development,  for  here  they 
can  do  more  for  the  human  race  than  at  any  other  time  of 
life,  and  the  people  are  coming  to  know  that  it  is  wiser  to 
employ  a  physician  to  superintend  the  physical  education  of 
girls  than  to  employ  him  to  cure  their  ill  health  during 
womanhood.  We  have  said  that  the  poor,  especially  in  large 
cities,  suffer  from  excessive  indoor  life,  from  the  effects  of 
imperfect  food,  and  all  other  conditions  which  come  from 
poverty  and  overcrowding,  the  consequence  being  that  they 
are  imperfectly  developed  generally.  The  children  of  the 
rich  or  well-to-do  class,  who  have  the  advantages  of  means 


SECONDARY  DIFFERENTIATION  OP  SEX  AT  PUBERTY.        23 

but  the  disadvantages  which  come  from  the  misuse  of  wealth, 
are,  in  this  country  at  least,  quite  as  liable  to  imperfect 
physical  development  as  any,  save  the  offspring  of  the  very 
poor. 

This  is  the  class  that  should  be  mentally  and  physically 
the  most  perfect,  for  they  have  ample  means  to  cultivate  both 
body  and  mind.  Yet  the  opportunity  has  not  been  improved. 
A  cause  here  of  defective  development  is  the  great  dispropor- 
tion between  the  time  given  to  care  of  body  and  of  mind. 

Unnatural  home  culture  and  school  education  overstimu- 
late  the  brain  and  nervous  system ;  and,  by  creating  mere 
excitability  without  force,  arrest  development  and  lay  the 
foundation  for  ill  health  and  failure  in  after-life.  Parents 
and  the  other  teachers  seem  to  have  but  one  idea,  and  that  is 
to  store  the  mind  with  knowledge  and  enforce  good  moral  be- 
havior. While  the  physician  advises  country  life,  rest  for 
the  brain,  and  care  of  the  body  for  girls  who  rank  high  as 
scholars  but  are  miserable  in  general  health,  the  reply  to  his 
counsel  often  is  that  they  will  thereby  neglect  their  educa- 
tion. They  fail  to  see  that  a  little  knowledge  gained  at  the 
expense  of  impaired  development  of  body  is  worse  than  use- 
less. A  knowledge  of  mathematics  and  astronomy  is  of  little 
value  or  comfort  to  a  pale,  bloodless  girl  who  suffers  from  in- 
digestion and  backache.  The  undue  amount  of  time  spent 
in  the  house,  in  company,  and  at  places  of  amusement,  the 
variety  of  objects  of  interest  which  crowd  around  her  w^hile 
in  the  street — all  tend  to  tax  the  brain  and  nervous  system  at 
the  expense  of  the  rest  of  the  body.  Lounging  in  easy- 
chairs  at  home  and  the  strained  sitting  posture  in  school  in- 
terrupt the  return  of  the  blood  from  the  lower  portion  of  the 
body.  That  keeps  up  an  engorgement  of  the  pelvic  organs 
which  retards  their  development  and  growth. 

Girls  are  occasionally  seen  in  this  grade  of  society  who  in- 
herit vigorous  digestive  organs  and  stolid  brains,  and  are 
therefore  little  disturbed  by  the  excitement  of  their  artifi- 
cial surroundings ;  such  are  typical  apatJiiques  in  tempera- 
ment.    They  become  fat  and  indolent ;  the  heart  and  blood- 


24  MEDICAL  aYNECOLOGY. 

vessels  remain  small  because  the  circulatory  system  has  little 
to  do.  The  sexual  organs  are  often  imperfectly  developed. 
These  girls  become  bloodless,  and  often  suffer  in  womanhood 
from  menstrual  derangements  and  sterility.  Their  abundance 
of  flesh  and  their  white  skins  give  them  an  appearance  of 
health  which  is  unreal,  and  they  are  incapable  of  anything 
approaching  the  highest  functional  activity.  Many  of  these 
peculiarities  are  inherited,  but  they  can  be  overcome  by 
proper  training  in  early  life. 

Bodily  defects  in  man  are  not  due  to  original  sin  ;  the  bad 
are  often  physically  better  than  the  good.  Man  has  given 
more  attention  to  the  physical  culture  of  the  lower  animals 
than  to  himself,  hence  the  former's  superiority. 

To  secure  normal  development  of  the  reproductive  organs 
is  to  secure  a  uniform,  harmonious  development  of  the  whole 
organization. 

True,  it  is  possible  to  have  a  high  degree  of  development 
and  functional  activity  of  one  portion  of  the  body  while  an- 
other may  be  markedly  defective ;  but  this  is  rather  acci- 
dental and  exceptional,  and,  when  it  does  occur,  the  portion 
that  is  well  developed  will  certainly  be  hampered,  to  some 
extent,  in  its  function  by  the  defects  elsewhere  present  in  the 
organization.  The  great  object  in  culture,  then,  should  be  to 
devote  the  greatest  care  to  that  portion  of  the  organization 
which  is  most  deficient.  The  reverse  of  this  is  very  often 
practiced  in  every-day  life,  as  has  already  been  stated.  The 
strong,  muscular  girl  is  often  permitted  to  exercise  and  neg- 
lect her  lessons,  while  the  delicate  one  with  a  large  active 
brain  is  encouraged  in  her  studies,  because  she  is  inclined 
that  way,  and  is  quick  to  learn.  The  result  generally  is  to 
make  the  sensitifs  more  so  and  the  apathiques  stiU  more 
stolid. 

The  best  way  to  get  at  this  proposed  system  of  culture  is 
through  a  study  of  the  temperaments.  It  has  been  a  habit 
among  medical  men  to  use  the  word  temperament  to  desig- 
nate a  condition  of  the  organization  in  which  one  or  more 
portions  or  systems  predominate— i.  e.,  that  are  more  highly 


SECONDARY   DIPPEHENTIATION   OF  SEX  AT   PUBERTY.        25 

developed  than  the  rest.  The  terms  nervous,  sanguine,  motor 
or  bilious,  and  lymphatic,  are  employed  to  indicate  tempera- 
ment as  manifested  by  physical  conditions.  The  actif,  sen- 
sitif,  and  apatMque  terms  are  used  to  indicate  the  disposi- 
tion or  functional  characteristics  of  the  temperaments.  When 
the  brain  and  nervous  system  are  better  developed  than  the 
rest  of  the  body,  the  person  is  said  to  have  the  nervous  tem- 
perament. When  the  heart  and  blood-vessels  are  propor- 
tionately large,  the  function  of  blood-making  active,  and  the 
hair  light  or  inclined  to  red,  the  temperament  is  sanguine, 
v^hen  the  fat-forming  process  predominates,  phlegmatic  or 
lymphatic.  The  girl  of  large  bones  and  muscles,  abundant 
dark  hair,  and  spare  habit  is  of  the  motor  or  bilious  tempera- 
ment. 

In  the  actif  and  the  apatMque  temperaments  the  digestive 
organs  and  assimilative  functions  predominate ;  such  are 
usually  good  livers  and  have  much  fatty  tissue. 

In  the  highest  type  of  development  there  is  a  well-bal- 
anced state  in  every  part  of  the  body  ;  the  temperaments  are 
harmoniously  blended,  and  we  have  an  actif- sensitif  or  a 
sens  it  if -act  if,  the  line  between  the  two  being  thinner  as  the 
type  nears  the  ideal.  I  believe  the  sensitif- actif  to  be  the 
most  desirable  type  for  woman. 

The  girl  with  a  highly  developed  nervous  temperament  is, 
say  pseudo- scientists,  best  fitted  for  brain  work,  while  the 
actif s  and  apatJiiques  should  do  physical  labor.  The  object 
of  that  theory  is  to  make  the  best  of  the  material  on  hand, 
but  it  does  not  tend  to  improve  the  race.  The  true  principle 
of  elevating  and  improving  the  human  race  is  to  equalize  the 
temperaments,  as  far  as  possible,  by  such  physical  and  men- 
tal culture,  occupation,  and  position  in  society  as  are  best 
adapted  to  the  improvement  of  the  defects  of  the  body  or 
mind.  If  this  principle  guides  the  culture  of  girls  from  in- 
fancy up  to  puberty,  the  sexual  organs  will  become  well 
developed  in  the  great  majority  of  cases.  Most  of  our  litera- 
ture upon  this  subject  is  devoted  to  the  care  of  girls  at 
puberty  —  that  is,  during   the   transition   from   girlhood   to 


26  MEDICAL   GYNECOLOGY. 

womanhood.  But  to  insure  a  satisfactory  transition  at  that 
time,  the  proper  culture  and  care  should  begin  at  birth  and 
continue  not  only  up  to  puberty,  but  during  the  whole  func- 
tional life  of  the  sexual  system. 

HOME   CULTURE. 

The  subject  of  home  culture  of  the  mind  is  far  too  great 
to  be  even  outlined  here.  All  that  can  be  done  will  be  to 
state  some  of  the  principles  of  mental  culture  which  bear 
directly  upon  the  question  of  sex.  The  chief  object  to  be 
accomplished  is  to  keep  the  emotions  under  the  control  of  the 
will  and  judgment  as  far  as  possible.  The  tendencies  of  the 
sexual  appetence  when  freed  from  the  guidance  of  instinct  is 
toward  error  and  extravagance.  Intelligence,  then,  is  the 
only  agency  through  which  the  emotions  can  be  kept  within 
legitimate  bounds.  To  obtain  the  required  adjustment  be- 
tween the  intellectual  and  emotional  in  the  mental  composi- 
tion necessitates  the  closest  attention. 

Self-control  is  one  of  the  great  lessons  to  be  learned  in 
early  life.  A  parent  should  begin  by  forming  in  a  child  a 
strong  will  and  a  sound  judgment.  These  lie  at  the  very 
foundation  of  all  culture.  It  renders  childhood  happier,  and 
is  the  best  preparation  for  life  in  womanhood.  It  lies  at  the 
foundation  of  the  ability  to  accommodate  one's  self  to  cir- 
cumstances. Many  a  woman  goes  through  life  uselessly 
struggling  to  make  her  surroundings  conform  to  her  desires, 
when,  by  accommodating  herself  to  her  environment,  she 
could  secure  contentment  and  happiness.  Indulgent  parents 
may  yield  to  every  whim  of  their  children,  and  thus  train 
them  to  expect  from  others  the  same  subservience  in  after- 
life, but  the  world  refuses  such  concessions  to  individual  de- 
mands. It  is  true  that  the  free-born  have  certain  inalienable 
rights  which  they  ought  to  assert ;  but  these  are  the  common 
inheritance  of  the  human  family,  and  hence  the  portion  of 
one  should  not  be  increased  at  the  expense  of  another.  The 
existence  of  such  attributes  implies  that  no  one  has  a  right, 
in  the  exercise  of  his  own  liberty,  to  disregard  the  liberty  of 


SECONDARY  DIFFERENTIATION  OF  SEX  AT   PUBERTY.        27 

others.  The  girl  who  has  had  her  own  way  in  childhood  will 
desire  the  same  concession  to  her  wishes  throughout  her  life. 
The  first  step  toward  acquiring  the  power  of  accommodation 
to  circumstances  is  to  learn  obedience  to  parents.  Every 
child  is  dependent  upon  others  not  only  for  support  and 
protection,  but  for  such  mental  and  moral  training  as  will 
best  prepare  it  for  self-control  and  intelligent  submission  to 
circumstances  and  the  laws  of  life.  If  these  lessons  are  neg- 
lected in  childhood,  when  they  may  be  easily  learned,  ex- 
perience will  be  a  harsh  teacher  in  after-life,  and  disease  and 
misery  will  be  the  lot  of  her  who  learns  only  after  an  unequal 
and  exhausting  struggle  that  the  world  can  not  be  molded 
to  her  will.  She  who  has  learned  to  limit  her  wants  in 
life  is,  perhaps,  more  fortunate  than  she  who  can  gratify  her 
many  desires. 

Obedience  to  laws,  whether  those  of  parents  or  of  Nature 
and  society,  is  not  necessarily  slavish  subjection.  It  only 
implies  a  knowledge  of  what  we  can  do,  what  we  can  acquire, 
and  what  we  can  contentedly  do  without.  Childhood  is 
often  made  unhappy  by  desires  and  cravings  which  can  not 
be  satisfied,  and  no  effort  is  made  to  teach  the  reason  why 
indulgence  can  not  be  granted,  and  to  show  that  contentment 
is  possible  without  the  gratification  of  every  selfish  wish.  By 
proper  control  the  nervous  system  is  freed  from  one  great 
source  of  irritation  in  youth,  and  is  strengthened  and  devel- 
oped in  that  direction  which  best  prepares  one  for  the  reali- 
ties of  adult  life.  Much  of  the  nervous  irritation  so  often 
seen  among  women  is  due  to  useless  desires  which  can  not  be 
gratified.  Unreasonable  indulgence  begets  selfishness,  which 
develops  self-consciousness.  Self-consciousness  is  one  of 
the  most  marked  predisposing  causes  of  nervous  disorders. 
Every  little  disturbance  of  the  mind  or  body  is  noted  and 
cherished,  and  an  impatient  desire  to  be  free  from  it  is  at 
once  awakened.  Selfishness  seeks  relief  from  every  care,  and 
if  that  is  not  promptly  obtained  useless  fretfulness  ensues. 
I^ervous  disorders  grow  and  thrive  by  nursing,  while  patient 
submission  and  forgetfulness  of  self  starve  them  out.     Con- 


28  MEDICAL  GYNECOLOGY. 

stant  introspection,  which  arises  from  selfishness,  circum- 
scribes the  mind  and  general  nsefulness.  With  such  persons 
no  impression  is  strong  or  lasting  unless  it  pertains  to  some- 
thing of  self.  When  the  family  teaching  has  established  this 
state  of  mind,  it  can  never  be  fully  overcome  in  after-life. 
All  efforts  to  enlarge  the  range  of  interest  are  generally 
futile.  The  mind  dwells  upon  its  own  follies  and  vain  de- 
sires, wrongs  and  injuries,  real  or  fancied,  and  cherishes 
them  with  miserly  care,  which,  sooner  or  later,  leads  to  a 
fixed  morbid  state  of  mind. 

To  protect  a  child  from  itself  and  teach  it  how  to  find 
material  for  mental  occupation  outside  of  self  is  to  lay  the 
foundation  for  much  mental  health  and  hajDpiness  in  after- 
life. The  children  so  taught  begin  life  under  the  best  condi- 
tions of  mental  hygiene,  and  are  likely  to  go  on  to  higher 
development.  They  will  continue  to  find  objects  of  interest 
in  the  world,  while  selfishness  early  acquired  can  hardly  ever 
be  overcome.  All  efforts  to  forget  self  and  find  enjoyment  in 
things  around  are  often  futile.  Intelligent  and  willing  obedi- 
ence to  immutable  laws — i.  e.,  the  power  of  adaptation  to  inevi- 
table circumstances — and  the  ability  to  find  interest  in  things 
outside  of  self,  are  most  easily  taught  in  the  home  circle  by 
parents.  If  these  lessons  are  not  inculcated  in  childhood,  the 
result  is  a  spoiled  child,  and  that  really  means  a  human  being 
spoiled  for  life.  A  girl  so  reared  at  home  is  constantly  an- 
noyed by  her  surroundings  in  after-life.  When  she  leaves 
home  as  a  bride  she  finds  that  others  have  claims  which  she 
ought  to  respect,  but  she  is  not  prepared  to  do  so.  She 
reigned  supreme  at  home  and  can  not  easily  yield  to  the  dic- 
tates of  others.  And  she  either  becomes  a  discouraged  good- 
for-nothing,  or  else  enters  upon  a  lifelong  war  with  the  world 
and  all  that  is  in  it.  Even  her  prayers  to  God  are  pleadings 
for  blessings  which  she  neither  needs  nor  deserves,  without  a 
word  of  thanksgiving. 

The  family  habits  in  America  tend  to  premature  develop- 
ment of  the  brain  and  nervous  system.  If  pushed  too  far,  the 
brain  of  the  child  never  reaches  either  its  normal  dimensions 


SECONDARY  DIFFERENTIATION  OF  SEX  AT   PUBERTY.        29 

or  mental  strength  in  adult  life.  There  is  scarcely  any 
childhood  here.  I  well  remember  that  the  first  thing  which 
attracted  my  attention  when  I  arrived  in  this  country  was  the 
precocity  of  the  children.  The  slow,  reserved  awkwardness 
to  which  I  had  been  accustomed  in  Europe  I  did  not  observe 
among  American  children.  They  were  all  mentally  mature 
beyond  their  years.  There  was  not  the  same  difference  be- 
tween the  adults  of  Europe  and  America.  A  more  careful 
study  of  the  children  has  convinced  me  that  their  chief  pecul- 
iarity is  mental  activity.  They  do  not  present  evidence  of 
greater  size  or  strength  of  brain,  but  much  greater  excitabil- 
ity and  activity.  At  home  and  in  schools  I  did  not  find  ex- 
traordinary capacity  for  long- continued  application,  nor  any 
marked  proficiency  in  specific  branches  of  knowledge,  but  a 
great  amount  of  general  information,  a  readier  application  of 
knowledge  acquired,  and  a  facility  of  thought  and  action  su- 
perior to  that  of  children  in  some  parts  of  Europe.  There 
are,  no  doubt,  many  circumstances  and  conditions  which 
give  rise  to  this  rapid  development  of  the  brain  and  nerv- 
ous system  in  this  country.  Climate,  the  restless,  ever- 
changing  condition  of  society,  the  mixing  of  races,  and  all 
the  stimuli  which  a  new  country  naturally  affords — all  these 
have  their  influence  upon  the  young.  In  this  connection 
attention  is  directed  to  the  home  influences.  Here  children 
associate  more  with  adults,  and  are  led  earlier  to  adopt  their 
habits  and  modes  of  life.  Children  occupy  the  same  rooms 
and  sit  at  the  same  table  with  their  parents.  They  are  less 
left  to  themselves,  in  cities  at  least,  and  as  adults  rarely  adapt 
themselves  to  children,  the  children  are  obliged  to  accommo- 
date themselves  to  the  ways  of  their  elders.  This,  to  a  certain 
extent,  is  as  it  should  be,  but  the  restless  activity  of  the 
American  people,  which  gives  too  little  time  for  social  life, 
has  its  influence  upon  the  young.  Boys  and  girls  soon  learn 
the  value  of  time,  and,  like  their  parents,  make  the  most  of  it. 
Unconsciously  they  catch  the  spirit  of  the  age  and  country, 
and  are  hurried  along  without  being  permitted  to  linger  in  the 
quiet,  irresponsible,  thoughtless  period  of  childhood. 


30  MEDICAL  GYNECOLOGY. 

The  value  placed  in  America  uj)on  every  human  being  is 
too  high  to  permit  any  one  to  remain  long  in  that  state  of 
mental  evolution  and  growth  which  is  best  fitted  to  develop 
strength  and  brain.  Any  precocious  specialization  is  dan- 
gerous, for  no  child  or  young  girl  can  show  all  their  apti- 
tudes. The  young  American  must  work  while  his  less  ener- 
getic neighbor  is  permitted  to  grow.  Too  much  time  is  spent 
in  action  and  not  enough  in  repose.  Too  much  forced  work 
and  not  enough  of  easy  play,  which  really  is  natural  occupa- 
tion. This  applies  to  cities,  the  worst  places  to  develop 
strong  children.  The  same  misfortune,  to  a  less  extent,  pre- 
vails in  the  country.  People  here  are  almost  all  striving  to 
better  their  condition.  By  industry  they  hope  to  rise  in  the 
world,  and  they  need  the  help  of  their  children  earlier  and 
to  a  greater  extent  than  among  the  fixed  populations  of  older 
countries  which  remain  more  stationary.  The  poor  children 
in  every  nation  have  to  work,  but  their  employment  in  old 
countries  has  more  routine  and  is  less  exciting  than  ours ; 
hence  I  presume  that  imperfect  development  is  in  Europe 
more  frequently  due  to  poor  food  than  to  overwork. 

There  is  yet  another  great  error  of  early  training  which 
prevails  in  all  countries,  but  jDerhaps  more  in  this  than  else- 
where— viz.,  the  cultivation  of  the  emotions  out  of  i)roj)or- 
tion  to  the  rest  of  the  brain  functions.  To  use  the  classifica- 
tion adopted  in  a  former  chajDter,  we  find  that  the  emotional, 
the  sensitif  temperament  predominates  among  the  girls  of 
America.  This,  added  to  their  intellectual  activity,  gives  the 
characteristic  brain  organization  of  this  country,  and  is  a  pre- 
disposing cause  of  nervous  affections.  The  management  of 
children  which  jDrevails  here  tends  to  jDroduce  these  peculiar- 
ities. The  prosperity  of  the  majority  of  the  people  enables 
them  to  indulge  their  affection  for  their  children,  and  that  in- 
dulgence begets  strong  affection  in  their  offspring.  The  deli- 
cate sensibilities  of  the  children  contrast  agreeably  with  the 
rude,  coarse  dispositions  of  a  less  fortunate  race.  Still,  those 
finer  feelings  in  children  are  the  products  of  a  high  but  per- 
haps misdirected  civilization,  and  sometimes  unfit  them  to 


SECONDARY  DIFFERENTIATION  OP  SEX  AT  PUBERTY.        31 

sustain  those  struggles  for  existence  whicli  often  fall  to  their 
lot  in  mature  years.  With  us,  hypersensitiveness  often  takes 
the  place  of  the  cold  indifference  of  barbarians,  but  a  wiser 
civilization  would  develop  a  nervous  organization  which  would 
be  controlled  by  the  intellect ;  kindness  and  mercy  would  be 
guided  by  justice  ;  benevolence  and  sympathy  would  go  hand 
in  hand  with  reason  ;  while  the  cruel  heartlessness  of  the  sav- 
age and  the  supersensitiveness  of  the  over-refined  would  be 
unknown. 

The  great  object  to  be  attained  is  to  keep  the  emotional 
temperament  under  the  influence  and  control  of  the  moral 
and  intellectual  nature.  This  can  be  accomplished  by  wis- 
dom in  training  during  childhood.  A  great  majority  of 
parents,  in  affectionate  fondling  of  their  children,  only  teach 
them  to  love  and  be  loved.  It  should  ever  be  borne  in  mind 
that  the  most  commendable  attributes  of  head  and  heart,  if 
developed  to  excess,  give  rise  to  evil,  and  should  therefore  be 
avoided. 


MENTAL  EDUCATION   OF   GIRLS  AT  PUBERTY. 

Usefulness  should  lie  at  the  foundation  of  a  girl's  educa- 
tion. It  does  not  to-day ;  and,  worse,  many  suffer  bodily 
injury  during  their  study  time.  My  own  record  of  cases 
shows  many  diseases  dating  from  a  girl's  graduation  from 
school,  college,  or  academy. 

A  girl  must  be  fitted  to  learn  rather  than  taught  sciences 
and  classics.  Housekeeping  should  form  as  important  a  sub- 
ject as  any  now  on  the  regulation  lists. 

Defects  in  our  system  of  education  are  active  causes  of  ill 
health. 

The  brain  alone  must  not  be  exercised,  the  rest  of  the 
organization  being  left  to  itself.  Each  student  should  have 
an  education  just  suited  to  herself,  the  weak  part  being 
braced  and  developed  in  body  or  mind. 

However  much  or  little  education  girls  receive,  her  phys- 
ical organization  demands  first  attention  ;  and  remember,  the 


32  MEDICAL   aYNECOLOGY. 

transition  from  girlhood  to  womanhood  usually  occurs  at  the 
height  of  school  life. 

In  school  a  girl  must  never  be  taxed  to  the  full  extent  of 
her  capacity,  and  undue  haste  in  accomplishing  an  educa- 
tion is  deplorable.  'Now  the  work  of  five  years  is  crowded 
into  three.  Headache,  indigestion,  and  insomnia  result. 
Shorter  hours,  less  competition,  more  sleep,  more  out-of- 
door  exercise,  and  more  time  at  meals  are  all  necessary  in 
modern  education. 

I  have  learned  from  the  experience  of  many  histories  to 
dread  the  name  of  my  graduation  year.  I  imagine  a  large 
part  of  the  Englishwomen's  good  health  is  due  to  their  ac- 
quiring less  knowledge  in  school  years. 

I  do  not  think  that  during  puberty  and  menstruation 
a  girl  necessarily  needs  rest  provided  the  scheme  outlined 
above  be  followed.  Moderate  mental  labor  greatly  aids 
health  at  all  ages  and  in  both  sexes.  "There  is  no  satis- 
faction and  content  like  that  following  work  done^  And 
after  work  comes  play  as  the  best  exercise — free,  unartificial 
play,  not  the  regular  exercise  of  a  gymnasium  or  "  trainer." 

It  is  wrong  to  require  as  much  mental  energy  from  a  girl 
in  school  as  from  a  man  in  active  business,  yet  this  is  daily 
done.  The  mind  can  early  be  stunted.  A  woman  in  the  rural 
districts  who  has  had  time  to  grow  bodily  healthy  has  great 
capacity  for  mental  exercise  later  on  in  life,  and  we  may 
have  a  poet,  author,  or  scientist.  Another,  who  has  enjoyed 
all  the  opportunities  for  high  education  in  the  best  colleges 
and  who  graduates  cum  laude,  is  never  heard  of  after.  They 
were  "trained  too  fine." 

To  fill  a  child's  head  with  facts  so  full  that  there  is  no 
room  for  common  sense  or  original  thought  is  no  education. 
It  is  best  to  teach  how  to  acquire  knowledge  and  to  manage 
what  is  already  known ;  they  can  work  with  the  means  ob- 
tained, later  in  life. 

Education  should  aim  to  make  women  in  all  that  the 
name  implies.  A  knowledge  of  how  to  be  attractive  and 
agreeable  is  a  power  of  great  value  to  a  woman,  who  wins  by 


SECONDARY  DIFFERENTIATION  OF   SEX   AT   PUBERTY.        33 

charming  and  attracting  those  who  are  to  guard  and  sustain 
her. 

Music,  art,  and  the  modern  languages  are  far  more  neces- 
sary to  woman  than  man.  And  personal  beauty  and  becom- 
ing dress  are,  I  believe,  too  often  to-day  obliterated  from  the 
girl  educator's  calendar. 

Of  what  avail  is  all  scientific,  linguistic,  and  philosophical 
knowledge  to  a  girl  if  she  knows  not  a  duty  of  the  home  ? 
No  girl's  education  is  worth  much  if  she  has  not  been  taught 
how  to  take'  care  of  children.  Whether  she  ever  has  any  or 
not  is  unimportant  compared  to  the  acquisition  of  this  part 
of  an  education. 

To  teach  anatomy  and  physiology  to  young  girls  is  bane- 
ful. 

What  a  mistaken  idea  to  direct  children's  attention  to  the 
structure  of  their  bodies  and  to  the  functions  of  organs  !  Of 
course,  all  should,  as  early  as  possible,  know  how  important 
— and  why — it  is  to  have  good  food  and  how  to  prepare  it,  a 
clean  person,  good  and  pure  air,  the  relations  between  rest 
and  sleep,  exercise,  and  how  and  when  to  take  it,  and  should, 
above  all,  be  taught  h.ow  to  obtain  these,  and  also  the  neces- 
sities of  life.  A  full  knowledge  of  hygiene,  so  far  as  it  is  re- 
lated to  one's  requirements  of  life  and  health  and  to  one's 
relations  to  the  world  around,  should  be  included  in  the  edu- 
cation of  every  girl.  It  is  only  when  investigation  is  carried 
beyond  this,  by  directing  the  attention  to  the  personal  anat- 
omy and  physiology,  that  the  mind  is  liable  to  become  per- 
verted. A  little  learning  in  anatomy  and  physiology  is  truly 
a  dangerous  thing.  The  heart  will  not  do  its  duty  more 
faithfully,  nor  will  the  stomach  digest  food  better,  because 
the  one  who  possesses  them  knows  all  about  their  structure 
and  functions.  On  the  contrary,  either  of  these  organs  may 
be  greatly  disturbed  by  thinking  about  them.  This  is  often 
illustrated  by  students  of  medicine,  who  for  want  of  proper 
subjects,  dead  and  living,  are  obliged  to  turn  their  attention 
to  their  own  bodies  as  a  means  of  illustration. 

To  study  the  structures  and  functions  of  one's  own  body 


34:  MEDICAL  GYNECOLOGY. 

is  a  kind  of  vivisection  which  is  nearly  always  followed  by 
bad  results.  Introspection  and  study  of,  and  watch  over,  one's 
symptoms  and  functions  are  excellent  means  to  pervert  and 
ruin  health.  This  road  to  ruin  is,  alas  !  often  opened  by  the 
physician  himself,  who  lays  too  much  stress  on  every  trivial 
symptom,  and  talks  too  much  in  the  presence  of  the  girl.  I 
have  great  apprehensions  about  those  patients  who  keep  a 
constant  watch  of  their  symptoms. 

IS'ext  to  the  doctor  in  the  order  of  mischief  makers  in  the 
business  of  producing  introspectors  is  the  intelligent  mother 
who  has  had  lessons  in  physiology.  Such  a  one  usually  in- 
jures her  own  children  and  those  of  her  neighbors  who  come 
within  reach  of  her  amateur  teaching  of  the  laws  of  life.  It 
is  ridiculous  to  tell  a  child  that  it  must  not  eat  candy  or  any- 
thing except  at  the  proper  meal  times,  because  it  will  injure 
the  stomach  and  cause  dyspepsia  and  general  ill  health  by 
exciting  the  secretion  of  gastric  juice  at  improper  times,  and 
creating  a  false  appetite  by  deranging  the  functions  of  the 
pneumogastric  nerve.  How  much  wiser  it  would  be  to  have 
a  child  obey  the  laws  of  health  because  its  parents  directed 
it  to  do  so  ! 

I  have  seen  children  thrive  best  who  first  obey  and  after- 
ward learn  the  reason  of  things.  At  first  it  is  absurd  to  "ap- 
peal ever  to  their  reason." 

Social  problems,  and  what  girls  should  know  concerning 
puberty,  menstruation,  and  the  sexual  organs,  are  seldom 
touched  upon  by  those  who  otherwise  are  excellent  teachers 
for  girls  ;  and  the  amateur  physiologist  and  psychologist  are 
thus  left  full  sway  to  work  great  mental  and  often  physical 
harm  in  those  who  are  destined  to  be  the  mothers  of  the  race. 


CHAPTER  III. 

MENSTEUATIOlSr. 

MEisrsTEUATioisr  is  a  function  or  physiological  process  which 
is  performed  periodically.  It  is  established  when  the  sexual 
organs  have  attained  their  complete  develoi^ment,  and  recurs 
at  stated  times,  excepting  during  gestation  and,  as  a  rule, 
during  lactation.  Many  theories  have  been  advanced  in 
ancient  and  modern  times  regarding  the  causation  of  menstru- 
ation, but  since  they  differ  so  much,  and  since  many  are  so 
obscure,  a  discussion  of  all  of  them  is  practically  valueless. 

Menstruation  is  almost  wholly  dependent  upon  the  influ- 
ence of  the  ovaries  in  the  economy,  since  the  flow  is  never 
established  in  those  in  whom  the  ovaries  are  congenitally 
absent  or  anatomically  defective.  Again,  those  who  have 
menstruated  in  a  perfectly  normal  way  for  years  cease  to  do 
so,  as  a  rule,  when  the  ovaries  are  removed.  The  same  cessa- 
tion of  menstruation  occurs  at  the  menopause,  when  the  ova- 
ries undergo  a  retrograde  degeneration.  I  take  it,  then,  that 
ovulation,  which  is  the  essential  function  of  the  ovary,  is  an 
initial  action  in  the  generative  cycle  and  awakens  the  neces- 
sity for  menstruation  in  the  uterus.  So  far,  then,  as  the  caus- 
ation of  menstruation  arises  in  the  sexual  organs,  the  ovaries 
are  certainly  the  most  important  factor.  It  has  often  been 
observed  that  ovulation  occurs  frequently  without  any  ap- 
parent relation  to  menstruation,  and  that  maturity  of  the 
ovule  in  the  Graafian  follicle  occurs  in  early  life  before  pu- 
berty ;  but  ovulation  at  this  time  is  not  complete,  since,  in 
most  cases  of  this  kind,  the  ovule  degenerates  without 
rupture  of  the  follicle. 

35 


36  MEDICAL   GYNECOLOGY. 

It  has  also  been  observed  that  ovulation  may  go  on  after 
the  menopause,  and  these  facts  have  been  offered  in  argument 
against  the  influence  of  ovulation,  or  ovarian  function  upon 
menstruation. 

Modern  physiology  clearly  proves  all  cell  activity  to  be 
very  much  more  dependent  upon  nerve  influence  than  upon 
blood  supply  or  any  other  systemic  condition. 

Menstruation  is  so  far  from  being  regarded  at  the  present 
day  as  mechanical  that  not  only  is  it  considered  a  "nervous 
function,"  but  a  special  nerve — the  menstruation  nerve  de- 
scribed by  Johnstone — has  been  found  as  its  governor. 

Many  well-known  events  strike  the  observer  as  strong  cir- 
cumstantial evidence  that  menstruation  depends  upon  the 
nerves — upon  the  nervous  system — probably  upon  a  special 
nerve  center. 

Among  these  are  its  periodicity ;  the  mental  (psychical) 
transformation  at  its  onset ;  the  perturbation  of  the  nervous 
system  at  its  subsequent  rhythmical  recurrence  ;  the  fre- 
quency of  pain  with  the  flow  ;  the  changes  in  vitality,  energy, 
and  metabolism  Just  around  the  period ;  the  peculiar  and 
well-known  emotional  and  mental  conditions  that  supervene 
upon  the  stoppage  of  this  periodical  flow  ;  and — what  the  least 
observant  must  have  had  forced  upon  him — the  premature 
oncoming  or  cessation  of  it  resulting  from  strong  emotional 
disturbance— as  a  rule,  sudden  and  unexpected. 

Comparative  anatomists  tell  us  about  uterine  contractions 
induced  by  direct  stimulation  of  many  pelvic  nerves,  and  they 
have  shown  conclusively  that  there  is  a  parturition  center  in 
the  lumbar  spinal  cord. 

There  is  probably  in  this  same  region  a  menstruation  cen- 
ter, from  which  the  pelvic  splanchnics,  starting  in  Clark's 
columns,  carry  impulses  that  run  along  Johnston's  nerve. 
This  trunk  enters  the  uterine  cornu  beneath  the  Fallopian 
tube,  starting  down  in  the  base  of  the  broad  ligament. 

While  the  existence  and  position  of  this  center  are  not  to- 
day as  certainly  known  as  those  of  the  vaso- motor  and  respir- 
atory centers,  nevertheless  impartial  experimentation  upon 


MENSTRUATION.  37 

animals  and  careful  dissections  upon  the  human  cadaver 
leave  little  in  doubt.  And,  too,  in  this  lumbar  enlargement 
of  the  spinal  cord  are  micturition,  defecation,  erection,  ejacu- 
lation, and  parturition  centers.  Why  not  a  menstruation 
center  ? 

Nerve  impulses  reach  the  uterus  from  the  ovarian  plexus 
as  well  as  by  way  of  the  pelvic  splanchnics,  in  which  plexus 
the  menstruation  nerve  is  found. 

Constructive  metamorphosis  in  the  uterine  mucosa,  proba- 
bly best  shown  in  the  preparation  of  a  decidua,  proceeds  be- 
tween the  menstrual  epochs,  the  organ  at  this  time  being 
influenced  by  anabolic  nerves  or  impulses.  But  periodically 
catabolic  influences  are  supreme,  and  destructive  metamor- 
phosis is  the  result :  menstruation  occurs. 

Many  who  claim  that  the  blood  supply  from  the  ovarian 
arteries  is  the  great  factor  in  menstruation  have  failed  to  see 
how  the  trend  of  modern  physiology  is  steadily  against  the 
association  of  functional  activity  with  blood  supply  alone. 
And,  again,  they  must  have  overlooked  the  fact  that  in  ligat- 
ing  the  ovarian  arteries  the  ovarian  plexus  is  simultaneously 
tied. 

Removal  of  both  ovaries  has,  in  a  few  cases,  caused  no 
cessation  of  menstruation.  Now,  if  in  the  ovaries  or  in  the 
tubes  lies  the  certain  cause  of  menstruation,  then  these  well- 
authenticated  events  could  never  by  any  possibility  have 
taken  place  ;  but  what  is  more  reasonable  than  to  imagine  the 
escape  in  a  few  operations  of  the  nerves  which  proceed  from 
a  menstruation  center  ? 

One  is  led  to  admire  the  deep  significance  of  the  term  syrri- 
pathetic  system  that  the  old  physicians  applied  to  certain 
nerves ;  and  a  constant  tendency  of  modern  investigation  is 
to  prove  how  many  complex  events  throughout  the  entire 
body  are  brought  about  from  local  changes  in  organs  in  con- 
nection with  these  sympathetic  nerves. 

Menstruation  depends  not  so  much  upon  one  factor  as  upon 
several  special  organs  and  functions.  The  ovaries  stand  pre- 
eminent in  the  causation,   and,    after  them,    the    nutritive 


38  '  MEDICAL   GYNECOLOGY. 

(blood)  supply,  the  spinal  nerves  and  their  associates,  and, 
lastly,  the  cerebral  influences  which  are  partly  voluntary  and 
partly  involuntary. 

Concerning  supplemental  nutritive  influence  or  jDlethora 
upon  menstruation,  it  is  certain  that  provision  is  made  in  the 
general  nutritive  system  for  sustaining  the  function  of  the 
uterus  in  the  perfonnance  of  the  function  of  menstruation, 
and*  in  yet  the  higher  and  more  complete  function  of  utero- 
gestation.  At  puberty  there  is  a  sup^Dlemental  nutrition, 
which  is  directed  to  the  sexual  organs  in  order  to  sustain 
them  in  the  performance  of  their  function.  That  there  is  an 
increased  determination  of  blood,  charged  ^vith  supplemental 
nutritive  material,  which  prepares  the  uterus  for  the  function 
of  gestation,  is  a  well-established  fact.  This  occurs  periodic- 
ally, and  if  gestation  or  conception  does  not  occur  when  the 
uterus  is  in  this,  its  highest  anatomical  development  and 
functional  activity,  menstruation  occurs,  apparently,  for  the 
purpose  of  eliminating  this  special  nutritive  material  which  is 
momentarily  useless  for  the  higher  demands  of  gestation. 

From  the  standpoint  of  the  scientist  this  brief  outline  may 
not  be  convincing  ;  but  for  the  practitioner — whose  chief  object 
is  to  have  some  rational  conce^Dtion  of  a  function  which  will 
enable  him  to  comprehend  the  conditions  under  which  it  is 
performed,  and  to  appreciate  the  nature  of  the  process  of 
menstruation,  so  that  its  derangements  and  their  causes  may 
be  clearly  comprehended — this  account  may  be  sufficient  and 
satisfactory. 

THE   ANATOMICAL   CHARACTERISTICS   OF   MENSTRUATION. 

There  are  still  some  differences  of  opinion  among  the  high- 
est authorities  regarding  the  anatomical  changes  which  occur 
in  the  endometrium  during  menstruation.  The  facts  which  I 
have  been  able  to  gather  from  these  authorities  are,  that  for 
a  few  days  preceding  the  menstrual  flow  the  mucous  mem- 
brane attains  its  highest  development.  The  entire  membrane 
becomes  very  much  thicker  than  at  any  other  time,  in  some 
cases  being  about  one  fourth  of  an  inch  in  thickness ;  on  the 


MENSTRUATION.  39 

surface  minute  depressions  are  observed,  at  tiie  bottom  of 
which  are  the  mouths  of  the  utricular  glands.  The  vascu- 
larity becomes  very  marked,  giving  a  dark-red  appearance  to 
the  membrane.  Then  the  epithelial  layer  undergoes  fatty 
degeneration,  and  the  fine  vessels  of  the  membrane,  thus 
denuded,  rupture,  and  hsemorrhage  takes  place.  The  extent 
to  vvrhich  this  fatty  degeneration  and  elimination  of  the  mu- 
cous membrane  occurs  is  estimated  differently  by  different 
observers.  ^  Williams  claims  that  the  entire  mucous  mem- 
brane undergoes  degeneration,  disintegration,  and  elimination. 
Others  limit  the  degeneration  to  the  epithelial  layer  chiefly. 

The  cause  of  the  hsemorrhage  is  probably  threefold: 
First,  the  v^eakening  of  the  vessel  walls  by  the  degeneration 
of  the  epithelial  layer ;  secondly,  by  the  general  hyperse- 
mia  of  the  uterus  ;  thirdly,  the  uterus  contracts,  and  so  in- 
creases the  tension  upon  the  capillaries  of  the  endometrium 
in  a  marked  degree.  Dr.  Johnston,  who  has  given  much 
time  and  attention  to  this,  expresses  the  idea  that  the  mu- 
cous membrane  of  the  uterus  acts  more  like  an  open  gland 
in  the  performance  of  its  function,  claiming  that  not  only 
is  there  fatty  degeneration  and  elimination  of  a  portion  of 
the  mucous  membrane,  with  rupture  of  the  capillaries  and 
hsemorrhage,  but  also  that  there  is  a  free  elimination  of 
leucocytes  and  nutritive  material,  so  that  menstruation  is 
more  closely  allied  to  a  glandular  secretion  than  anything 
else.  His  views  have  always  seemed  to  me  to  be  more  ac- 
curate and  in  accordance  with  the  actual  facts  than  any 
other.  They  certainly  correspond  with  the  idea  that  the 
mucous  membrane  prior  to  menstruation  is  prepared  to  take 
up  the  function  of  develoj)ment  of  the  embryo,  and  not  being 
called  upon  to  do  so  because  of  absence  of  impregnation  and 
conception,  the  nutritive  material  stored  up,  so  to  speak,  in 
the  uterus  is  eliminated  in  menstruation. 

CONDITIONS   NECESSARY  TO   NORMAL   MENSTRUATION. 

Regarding  the  conditions  necessary  to  normal  menstru- 
ation, we  possess  more   definite   knowledge   than  upon   the 


40  MEDICAL  GYNECOLOGY. 

theory  of  menstruation  itself.  The  first  condition  is  that  the 
general  organization  should  have  attained  its  complete  de- 
velopment ;  the  sexual  organs  (ovaries  and  uterus)  should 
be  fully  developed  and  in  a  normal  condition,  so  far  as  free- 
dom from  marked  organic  disease  exists  ;  there  should  be 
an  abundant  supply  of  nutrient  material,  which  presupposes 
that  the  general  organization  is  in  a  normal  condition  ;  there 
should  be  normal  innervation,  and  the  environment  should 
be  agreeable  to  the  whole  being. 

Menstruation  being  thus  dependent  upon  these  various 
conditions,  the  normal  performance  of  this  function  is  evi- 
dence of  a  fair  degree  of  health  of  the  general  organization  and 
of  the  sexual  organs.  This  is  important,  because  it  is  a  sort 
of  index  to  the  general  condition  of  the  individual.  On  the 
other  hand,  derangement  of  this  function  suggests  at  once  to 
the  physician  that  there  must  be  some  lesion  of  the  organiza- 
tion or  mal-environment  which  is  responsible  for  this  impaired 
or  deranged  function.  This  necessitates  keeping  in  view  not 
only  the  conditions  upon  which  the  function  is  dependent, 
but  the  laws  which  govern  it.  The  first  is,  that  menstruation 
should  be  established  when  the  general  organization  has  at- 
tained its  development  and  the  sexual  organs  have  under- 
gone secondary  development  or  maturation ;  that  the  func- 
tion should  recur  periodically  and  with  regularity,  say,  every 
twenty-eight  days,  and  that  it  should  continue  from  four  to 
eight  days,  according  to  the  characteristics  of  each  individ- 
ual ;  that  the  flow  should  amount  to  from  four  to  eight 
ounces,  and  that  this  function  should  continue  uninterrupted 
until  the  menopause,  at  about  the  forty-fifth  year,  except 
when  it  is  supplanted  by  the  higher  uterine  function  of 
utero- gestation,  or  is  absent  because  of  lactation.  The  char- 
acter of  the  flow  should  be  somewhat  uniform — that  is  to  say, 
it  should  be  free  from  coagula,  indicating  that  probably  it 
contains  less  fibrin  than  normal  blood  ;  it  should  contain  the 
debris  of  the  exfoliated  mucous  membrane,  and  should  have 
more  leucocytes  in  it — perhaps  also  more  phosphoric  and 
lactic  acid — than  blood  of  the  general  circulation. 


MENSTRUATION.  41 

While  there  is  some  uniformity  among  women  in  regard 
to  all  the  laws  of  menstruation  that  have  been  mentioned, 
there  is  yet  a  great  variation  therefrom.  The  age  at  which 
menstruation  appears  differs  greatly  according  to  climate, 
heredity,  environment,  hygiene,  health,  and  disease ;  but 
it  should  begin  when  general  development  is  complete,  or 
nearly  so,  and  not  before,  and  it  should  not  remain  absent 
afterward.  With  reference  to  the  time  of  recurrence,  dura- 
tion, quantity,  and  to  some  extent  the  character  of  the 
flow,  there  is  also  a  great  variation.  It  appears  that  each 
individual  is  a  law  into  herself  for  each  of  these  factors  ;  but 
when  once  certain  rules  are  established  in  a  given  case  they 
should  be — in  fact  they  are — maintained  during  good  health 
and  under  favorable  circumstances  ;  and  any  marked  devia- 
tion is  indicative  of  some  defect  in  the  conditions  necessary 
to  normal  menstruation, 


CHAPTER   ly. 

DEEANGEMEjS^TS   of   ME]SrSTEUATIO]S^   (GEIfERAL   MAL- 

developmejstt). 

Two  important  points  here  demand  consideration :  The 
discovery,  jirst^  of  the  nature  of  the  derangement ;  and,  sec- 
ondly^ of  the  defective  condition  or  conditions  inducing  the 
imperfect  function. 

Premature  menstruation  first  demands  attention.  By 
this  is  meant  that  the  menstrual  flow  is  established  before 
the  individual  has  completed  general  development.  The  in- 
dications determining  that  menstruation  is  premature  are : 
The  subject  shows  clearly  in  form  and  outline  that  the  transi- 
tion from  girlhood  to  womanhood  has  not  been  attained  ;  the 
mammary  glands  have  not  been  completely  developed  ;  the 
evidences  of  maturity  of  the  external  organs  of  generation 
are  wanting  ;  the  pelvis  has  not  attained  the  female  type,  and 
the  mental  characteristics  of  maturity  are  not  defined. 

The  history  of  cases  of  premature  menstruation  differs 
widely  in  different  cases ;  but,  as  a  rule,  the  appearance  of 
the  menstrual  flow  is  preceded  by  more  or  less  headache, 
backache,  a  sense  of  fullness  or  pelvic  pressure,  increased  vas- 
cular tension,  and  general  malaise.  These  various  symptoms 
are  summed  up  in  the  expression  menstrual  molimen.  This 
may  pass  off  in  a  few  days,  to  recur  after  three  or  four 
weeks,  and  then  the  menstrual  flow  appears.  It  is  under- 
stood that  the  subject  is  too  young,  too  small,  and  usually 
not  in  vigorous  health — in  other  words,  that  the  general  de- 
velopment has  not  been  completed.  In  some  cases  there  is 
evidence  that  the  secondary  development  of  the  sexual  organs 

42 


DERANGEMENTS  OP  MENSTRUATION.  43 

has  been  completed  ;  in  other  words,  sexual  development  has 
run  ahead  of  general  development. 

In  another  type,  while  there  is  a  premature  development 
of  the  sexual  organs,  it  is  still  incomplete.  Nearly  all  in  this 
class  give  evidences  of  premature  sexual  development,  as 
shown  by  the  increase  in  the  mammary  glands  and  the  pelvic 
outlines  and  external  sexual  organs,  the  usual  signs  of  puber- 
ty in  various  degrees  of  completeness.  And  even  when  men- 
struation is  established  it  is  seldom  normal.  More  pain  and 
general  disturbance  attend  it  than  are  usual.  The  flow  is 
often  short  in  duration,  and  contains  coagula.  In  some  cases 
the  flow  is  profuse  and  lasts  too  long,  and  has  a  markedly 
depressing  effect  upon  the  general  strength.  In  the  majority 
the  flow  does  not  return  regularly,  intervals  of  two  to  six 
months  often  occurring ;  but  in  those  who  have  a  free  flow, 
the  function  occasionally  appears  every  two  or  three  weeks. 

The  cause  of  this  premature  menstruation  is  in  a  large 
measure  heredity  ;  evidence  of  this  is  obtained  from  the  moth- 
er's history.  Next,  and  perhaps  more  important  in  the  way 
of  causation,  is  immoral  environment,  as  shown  in  the  form 
of  unwholesome  associations.  Neglected  children  among  the 
very  poor  and  very  rich,  and  also  unoccupied  young  girls,  fre- 
quently associate  with  older  and  somewhat  depraved  acquaint- 
ances, and  have  their  attention  directed  to  the  sexual  organs 
prematurely.  Improper  education  also  has  much  to  do  with 
this.  Bad  habits  acquired  from  local  irritations,  such  as  as- 
carides  in  the  rectum  and  want  of  cleanliness  of  the  external 
genitals,  are  potent  factors. 

Not  infrequently  adhesions  of  the  prepuce  to  the  glans 
clitoridis,  beneath  which  caseous  secretions  accumulate,  pro- 
duce a  local  pruritus,  which  is  further  aggravated  by  the 
subject  seeking  relief  by  additional  irritation ;  in  other 
words,  the  habit  of  masturbation,  which  is  acquired  by  un- 
fortunate associations  or  from  local  irritation,  is  a  fruitful 
cause  of  premature  menstruation.  Finally,  imperfect  inner- 
vation coming  through  hereditary  influences  or  from  over- 
stimulation, which  results  in  precocity,  may  induce  it.     This 


44  MEDICAL  GYNECOLOGY. 

overexcitability  of  the  brain  and  nervous  system,  I  am  cer- 
tain, leads  to  premature  menstruation,  because  I  have  quite 
frequently  found  this  derangement  in  the  establishment  of 
this  function  among  this  class  of  girls. 

In  the  treatment  of  this  abnormal  condition  the  patient 
should  be  removed  from  all  sources  of  excitement,  and  while 
agreeably  occupied  mentally,  rest  should  be  secured  and  in 
an  even  temperature.  If  the  patient  is  attending  school,  it  is 
better  that  she  should  be  kept  at  home  so  as  to  carry  out 
more  fully  these  necessary  attentions.  If  there  is  much  pain 
it  should  be  relieved  by  bromides  or  some  of  the  coal-tar 
products.  It  is  important  that  this  rest  and  care  should  be 
kept  up  after  the  flow  subsides  in  order  to  secure  a  complete 
post-menstrual  involution.  After  this  the  treatment  should 
consist  in  removing,  as  far  as  possible,  the  causes  that  are 
responsible.  If  local  irritations  exist,  they  should  be  re- 
lieved, and  associations  with  unsuitable  companions  should 
cease.  In  short,  the  object  is  to  divert  the  nutritive  forces 
from  the  sexual  organs  so  that  menstruation  shall  not  be 
continued  regularly,  in  order  that  general  development  may 
be  encouraged  to  go  on  to  its  completion.  All  symptoms 
of  nervous  disturbances  should  be  met  by  a  suitable  occupa- 
tion and,  if  necessary,  by  drugs  ;  and  general  nutrition  must  be 
improved  and  maintained  in  the  most  perfect  manner  possible. 

Premature  Puberty. — Closely  associated  with  premature  men- 
struation is  premature  puberty,  in  which  the  development 
generally  is  premature.  The  sexual  characteristics  in  these 
cases  appear  at  too  early  an  age,  and  growth,  to  a  corre- 
sponding degree,  falls  short.  Such  cases,  in  this  country  at 
least,  attain  their  maturity  at  a  time  that  would  be  normal 
in  some  of  the  tropical  climes.  They  really  have  a  very  short 
girlhood ;  apparently  seem  going  from  childhood  directly  to 
womanhood.  The  laity  call  them,  and  I  think  very  properly, 
"  old-fashioned  young  ones."  They  prematurely  become  lit- 
tle weakly  women. 

Here  menstruation  occurs  in  accordance  with  the  law 
which  establishes  this  function  when  general  development  is 


DERANGEMENTS  OP  MENSTRUATION.  45 

complete.  The  deviation  from  the  normal  is  the  premature 
development  of  the  general  organization  and  the  sexual  sys- 
tem included. 

The  cause,  as  in  the  previous  condition,  I  again  believe  to 
be  heredity.  Most  of  these  cases  I  have  seen  among  the 
daughters  of  women  who  developed  prematurely.  I  have  no 
doubt,  however,  that  mental  or  physical  overtaxation,  or 
both,  has  much  to  do  with  producing  this  premature  and 
consequently  imperfect  development. 

In  the  treatment  of  these  cases  little  can  be  accomplished 
beyond  giving  attention  to  the  general  health  and  occupation 
of  the  patient.  All  overtaxation  should  be  carefully  avoided, 
and  general  nutrition  must  be  maintained  in  order  that  the 
patient  may  have  time  to  grow;  her  development  having 
been  completed  in  a  premature  and  perhaps  rather  imper- 
fect way,  it  is  only  within  the  power  of  the  physician  to  see 
to  the  general  health  in  order  that  the  growth  of  the  individ- 
ual may  not  be  retarded,  but  encouraged  to  its  uttermost. 

RETARDED  OR  DELAYED  PUBERTY. 

The  most  marked  cases  of  this  kind  are  seen  in  those  in 
whom  the  ovaries  or  uterus  are  absent  or  entirely  rudiment- 
ary. In  such  cases,  while  general  development  may  go  on 
in  a  normal  way,  the  sexual  characteristics  are  never  devel- 
oped. All  the  sexual  organs  remain,  as  a  rule,  in  a  rudiment- 
ary condition,  and  in  place  of  the  sexual  characteristics  of 
body  and  mind  becoming  apparent  at  the  proper  age,  the  girl's 
development  stops  or  else  assumes  the  character  of  a  common 
or  mixed  type,  not  wholly  masculine  nor  yet  wholly  femi- 
nine, yet  rather  inclining,  physically  at  least,  to  the  masculine 
type. 

The  cause  seems  absolutely  unknown.  The  condition 
can  not  be  attributed  to  heredity  or  to  any  of  the  known 
causes  of  arrest  of  development  during  early  life.  It  is  pos- 
sible that  it  is  due  to  some  disease  or  derangement  during 
embryonic  evolution.  It  may  come  from  such  constitutional 
conditions  as  chlorosis,  plethora,  or  tuberculosis.     There  is  no 


46  MEDICAL  GYNECOLOGY. 

difficulty  in  determining  the  condition — in  other  words,  in 
making  a  diagnosis — because  it  is  easily  seen  that,  while 
the  subject  has  passed  the  period  of  puberty,  all  the  sexual 
characteristics  are  lacking,  excepting  that  the  external  geni- 
tal organs  are  of  the  feminine  type.  K'either  is  there  any- 
thing that  can  be  done  to  change  or  improve  such  cases, 
hence  treatment  need  not  be  discussed. 

RETARDED  PUBERTY,  WITH  PARTIAL  DEVELOPMENT  OP 
THE  SEXUAL  ORGANS. 

We  not  infrequently  observe  cases  where  general  bodily 
development  and  general  health  are  complete  and  excellent, 
and  where,  to  a  certain  extent,  the  sexual  organs  have  gone 
on  toward  their  full  development.  But  while  all  the  evi- 
dences of  maturity  exist  and  the  girl  is  old  enough  to  men- 
struate, she  fails  to  do  so. 

An  examination  reveals  no  arrest  of  general  development. 

There  is  no  history  that  tells  of  obstruction  of  a  flow  ;  no 
history  of  any  symptoms  that  announce  the  oncoming  of  one. 

In  making  a  diagnosis  of  such  a  case  the  climate  should 
of  course  be  primarily  considered ;  between  the  Hindoo  and 
the  Eskimo  a  period  of  three  years,  at  least,  represents  the 
difference  of  the  time  of  commencement  of  this  function,  and 
girls  in  towns  begin  to  menstruate  sooner  than  girls  in  the 
country. 

Causation. — This  condition  is  usually  caused  by  the  nu- 
tritive forces  being  directed  toward  the  general  organization. 
Such  subjects  generally  have  enough  of  physical  exercise,  in 
fact,  sometimes  too  much,  as  shown  by  those  that  are  fond  of 
outdoor  sports,  and  do  a  reasonable  amount  of  mental  work. 

Environment  has  a  great  deal  to  do  with  these  cases  of  de- 
layed menstruation.  Among  the  poorer  classes,  outside  of 
cities,  who  perform  a  great  deal  of  hard  manual  labor  out  of 
doors,  who  begin  work  early  in  life  and  in  whom  bones  and 
muscles  are  well  developed,  menstruation  is  often  delayed. 

Again,  active  brain- workers  in  good  health,  but  who  are 
largely  cut  oS  from  social  intercourse,  also  exhibit  this  delay. 


DERANGEMENTS  OF  MENSTRUATION.  4Y 

Here  there  must  be  a  want  of  balance  between  tlie  nutritive 
and  reproductive  systems  from  overwork  of  the  higher  func- 
tions in  the  latter  case,  and  of  the  more  mechanical  functions 
in  the  first-named  instance. 

Treatment. — When  delayed  menstruation  or  retarded  pu- 
berty arises  from  excessive  physical  work,  the  body  should 
have  rest  and  the  mind  should  be  given  work.  Any  de- 
rangement of  innervation  or  nutrition  must,  of  course,  at  the 
same  time  be  corrected. 

On  the  other  hand,  if  close  occupation  in  mental  work  is 
the  cause,  then  rest  of  mind  and  more  agreeable  social  sur- 
roundings should  be  prescribed.  Recently  I  have  seen  an 
illustration  of  each  of  these  classes. 

The  daughter  of  a  well-to-do  farmer  was  brought  to  me, 
and  although  she  was  old  enough,  sufficiently  well  developed, 
and  in  good  health,  she  had  never  menstruated.  I  found 
that  she  was  largely  occupied  with  dairy  and  farm  work, 
and  had  had  but  little  opportunity  for  diversion  or  men- 
tal exercise.  I  recommended  that  she  should  be  brought  to 
the  city  and  sent  to  school.  The  change  of  occupation  and 
surroundings  and  the  agreeable  mental  stimulation  were  suf- 
ficient to  establish  menstruation,  and  it  has  since  continued 
normal.  At  the  same  time  I  had  a  young  lady  from  a  board- 
ing school  who  came  here  from  a  country  town  to  complete 
her  education ;  she  was  well  developed  in  every  respect,  en- 
Joyed  good  health,  and  was  a  remarkably  good  scholar — 
without  being  brilliant  or  precocious — devoting  her  time  to 
her  studies,  and  with  no  desire  to  take  part  in  the  frivolities 
or  amusements  of  her  associates.  When  she  was  eighteen  her 
mother  and  her  teacher  became  anxious  about  her  not  hav- 
ing menstruated,  and  she  was  brought  to  me.  I  advised  her 
to  give  up  her  severer  studies,  to  continue  her  music,  to  go 
to  places  of  amusement,  and  into  society ;  in  other  words,  to 
change  the  whole  order  of  her  life.     She  recovered. 

To  formulate  this  in  another  way  I  may  say  that  in  the 
transition  stage  from  girlhood  to  womanhood  irregular  and 
imperfect  development  is  no  doubt  caused  in  many  cases 


48  ■    MEDICAL  GYNECOLOGY. 

by  heredity,  and  in  those  cases  where  there  is  a  hereditary 
tendency  to  imperfection  of  structure,  mal-environment  exer- 
cises its  strongest  influence  in  bringing  them  about. 

These  may  be  arranged  in  two  classes :  first,  those  cases 
where  there  is  some  arrest  of  development ;  and,  secondly, 
where  there  is  faulty  structure  either  in  the  general  organiza- 
tion or  in  the  sexual  organs.  The  general  organization  may 
be  so  imperfect  as  to  be  unable  to  complete  the  development 
of  the  sexual  organs,  or  if  the  latter  are  well  developed  the 
general  nutritive  system  becomes  unable  to  sustain  them  in 
their  highest  functional  activity.  The  results  are  often  the 
same,  while  the  lesion  may  be  now  in  the  general  organization 
and  now  in  the  sexual  organs  alone. 

Another  class  is  that  wherein  there  is  no  imperfection  of 
development,  but  the  whole  structure  is  not  well  balanced. 
There  is  a  lack  of  harmony  between  the  different  portions  of 
the  organization :  for  example,  all  the  viscera  may  be  well 
developed  and  in  a  fair  degree  of  healthful  activity,  but  the 
brain  and  nervous  system  may  predominate  to  such  an  extent 
that  their  demands  can  only  be  satisfied  at  the  expense  of  the 
rest  of  the  economy.  Again,  take  the  chlorotic  girl  who  may 
have  all  the  characteristics  of  the  sex  and  a  fair  degree  of  de- 
velopment, but  in  whom  the  circulatory  apparatus  is  under- 
sized, and  hence  the  whole  organization,  including  the  sexual 
organs,  suffers  to  a  certain  extent  from  malnutrition. 

ABNORMAL  DEVELOPMENT  OF  THE   SEXUAL   ORGANS, 
CHIEFLY  IRREGULARITIES   IN  EVOLUTION. 

Premature  Development  of  tlie  Sexual  Organs.— In  this  class 
of  cases  the  development  of  the  sexual  organs  begins  too 
early  and  goes  on  in  a  regular  and  normal  way  so  far  as 
the  structure  of  the  sexual  organs  is  concerned.  It  is  abnor- 
mal simply  because  it  is  premature.  The  development  of  the 
sexual  system  takes  place  before  the  general  organization  is 
sufficiently  matured  to  sustain  it  in  the  performance  of  its 
function.  The  evidence  of  this  premature  transition  from 
girlhood   to  womanhood  is  that  it  becomes  observable  too 


DERANGEMENTS  OP  MENSTRUATION.  49 

early  in  life  ;  but  since  there  is  great  latitude  in  regard  to 
the  time  when  girls  attain  puberty,  it  is  only  shown  to  be 
abnormal  when  the  general  organization  does  not  keep  pace 
in  growth  with  that  of  the  sexual  system. 

The  cause  is  largely  a  matter  of  mal- environment  and 
heredity.  In  many  of  these  cases  I  have  found  that,  accord- 
ing to  the  history,  the  parents  were  undersized,  and  the 
mother  matured  early.  When  this  is  the  case,  environment 
acts  more  effectively  in  producing  the  irregularity.  It  not 
infrequently  occurs,  however,  when  there  is  no  hereditary 
tendency  to  this  early  puberty,  that  it  is  brought  about  by 
associations  which  direct  the  attention  of  the  child  to  the 
subject  of  procreation  or  rejDroduction,  and  hence  the  prema- 
ture development  may  be  traced  directly  to  deranged  inner- 
vation—overstimulation of  the  emotional  temperament,  as  I 
have  ventured  to  call  it. 

Treatment. — If  seen  at  the  outset  much  can  be  done  by 
diverting  the  attention  of  the  child  from  the  sexual  system. 
This  can  be  effected  chiefly  through  suggestion,  parents  and 
teachers  directing  the  mind  to  other  subjects,  giving  it  a  cer- 
tain amount  of  rest  by  imposing  fewer  studies,  less  mental 
work  and  more  physical  exercise,  so  as  to  develop  the  respir- 
atory, circulatory,  and  muscular  systems.  This  might  be 
called  treatment  according  to  the  therapeutic  rule  of  deriva- 
tive action. 

DERANGEMENTS  OF  MENSTRUATION  FROM    MALFORMA- 
TIONS  OF   THE    OVARIES. 

From  what  has  been  said  regarding  the  influence  of  the  ova- 
ries on  the  general  and  sexual  systems,  it  will  be  understood 
,  that  the  ovaries  are  necessary  to  menstruation,  and  that  any 
defect  of  the  ovaries  will  derange  the  functions  of  the  uterus. 

When  the  ovaries  are  absent  the  whole  being  is  imperfect 
and  peculiar,  and  the  physician  is  powerless  to  aid.  His 
function  ends  when  he  has  made  a  diagnosis.  Menstruation 
does  not  occur,  nor  is  there  any  need  for  it,  and  hence  treat- 
ment is  useless. 


50  MEDICAL  GYNECOLOGY. 

There  are  cases  in  which,  by  inference,  the  ovaries  are  pre- 
sumed to  be  imperfectly  developed  and  menstruation  is  im- 
perfect. Such  women  menstruate  at  long  intervals  and  then 
only  for  a  short  time.  They  are  usually  phlegmatic  and  de- 
fective in  sexual  instinct.  The  diagnosis  is  made  by  exclu- 
sion, and  the  treatment  is  nil.  If  such  cases  are  seen  early 
in  life,  they  may  be  improved  by  the  general  management 
recommended  in  cases  of  delayed  puberty.  Such  cases  are 
seldom  seen  until  later  in  life.  They  generally  enjoy  fair 
health,  and  it  is  not  until  after  puberty,  when  they  notice  the 
derangements  or  imperfect  menstruation,  that  they  seek  the 
advice  of  the  physician. 

DERANGEMENTS  OF  MENSTRUATION  FROM  MALFORMA- 
TIONS   OF  THE   UTERUS. 

There  are  a  great  number  of  malformations  of  the  uterus, 
the  majority  of  which  are  due  to  arrest  of  development  at 
the  various  stages  of  evolution  either  in  embryo  or  at  the 
period  of  puberty,  when  secondary  development  takes  place. 
Paradoxically  placed  among  these  is  one  generally  described 
as  absence  of  the  uterus ;  but  when  the  ovaries  are  present 
there  is,  as  a  rule,  a  rudiment  of  a  uterus,  although  it  is  very 
little  more  than  a  short,  cordlike  mass  of  fibrous  tissue. 
Amenorrhoea  occurs  in  this  class. 

With  this  rudimentary  condition  of  the  uterus  when  asso- 
ciated with  the  presence  of  normal  ovaries,  the  subject  usu- 
ally develops  all  the  characteristics  of  sex  completely  at 
puberty,  but  fails  to  menstruate.  There  is  a  marked  men- 
strual molimen,  and  in  some  cases  there  is  vicarious  menstru- 
ation. The  severity  of  the  symptoms  of  the  menstrual  moli- 
men generally  increases  from  month  to  month,  and  the  pa- 
tient's general  health  deteriorates.  The  nervous  system  exhib- 
its the  bad  effects  of  this  physical  defect  by  headaches,  some- 
times inactivity,  drowsiness,  and  subsequently  gastric  and 
hepatic  derangements.  These  latter  are  at  times  acute,  and 
the  patient  will  be  seized  with  gastralgia,  nausea,  and  vomit- 
ing, and  now  and  then  an  acute  attack  of  diarrhoea.     It  is 


DERANGEMENTS  OP  MENSTRUATION.  51 

usually  after  the  recurrence  of  these  attacks  that  the  patient 
seeks  advice  of  the  physician.  When  the  evidences  of  devel- 
opment are  satisfactory  and  there  are  no  indications  of  ill 
health,  excepting  nervous  and  digestive  disturbances,  and 
after  the  ordinary  treatment  for  the  relief  of  these  has  failed 
to  bring  on  the  menstrual  flow,  it  is  necessary  and  right  that 
the  patient  should  be  examined,  to  discover  the  condition  of 
the  pelvic  organs.  Perhaps  a  doubt  may  at  first  exist  in  the 
mind  of  the  practitioner  as  to  v^hether  there  may  not  be  an 
imperforate  hymen  ;  but  if  several  months  have  elapsed  since 
the  completion  of  development,  or  the  arrival  of  puberty,  and 
there  is  from  the  history  no  evidence  of  distention  of  the 
vagina  and  uterus,  one  may  strongly  suspect  that  the  diffi- 
culty is  some  malformation  of  the  uterus,  and  here  also  an 
examination  becomes  necessary.  As  a  rule,  I  deem  it  expe- 
dient to  give  an  anaesthetic  (nitrous-oxide  gas  being  by  far 
the  most  satisfactory),  and  then  a  digital  examination  may 
enable  one  to  find  the  uterus,  or  to  find  that  it  is  only  pres- 
ent in  the  rudimentary  condition.  As  this  malformation  is 
sometimes  associated  with  atresia  of  the  vagina,  which  pre- 
cludes the  possibility  of  making  the  digital  examination,  the 
condition  may  only  be  determined  by  rectal  touch.  It  has 
been  suggested  to  use  a  sound  in  the  bladder  at  the  same 
time  that  rectal  touch  is  practiced,  but  I  hardly  think  this  is 
ever  necessary.  If  the  uterus  is  absent,  or  what  practically 
amounts  to  the  same  thing,  there  is  only  a  small,  cordlike 
mass  in  the  place  where  the  uterus  ought  to  be,  this  will  be 
information  sufficiently  accurate  to  guide  the  gynecologist 
in  the  management  of  the  case. 

Causation. — There  is  really  very  little  known  about  the 
causes  of  many  of  these  malformations ;  they  are  no  doubt 
exerted  during  embryonic  life,  and  on  that  account  are  not 
easily  discovered.  We  may  say  it  was  due  to  some  disease 
of  the  embryo,  but  this  is  self-evident  and  affords  no  explana- 
tion of  the  facts. 

Treatment. — When  we  find  a  patient  at  puberty  with  the 
absence  of  the  uterus,  or  a  rudimentary  uterus,  there  is  noth- 


52  MEDICAL  GYNECOLOGY. 

ing  that  medicine  or  surgery  can  accomplisli  to  partially  or 
wholly  complete  the  process  of  development.  All  efforts 
must  be  directed  to  relieving  the  patient  from  the  conse- 
quences of  the  tendency  to  menstruate,  owing  to  the  presence 
of  the  ovaries.  The  danger  is,  that  the  menstrual  molimen 
will  increase  in  severity  and  that  the  constitutional  disturb- 
ances will  also  become  more  marked.  The  baneful  effects  of 
the  absence  of  menstruation,  owing  to  the  absent  or  rudi- 
mentary state  of  the  uterus,  increase  as  time  goes  on.  The 
headache  and  nervous  disturbances  of  nutrition  increase  until 
not  infrequently  the  patient  has  convulsions  at  the  menstrual 
periods,  and  may  temporarily  become  partly  deranged  in 
mind.  At  first  there  is  a  sort  of  plethoric  condition,  and 
there  seems  to  be  a  retarded  elimination  owing  to  imperfect 
excretion  on  the  part  of  the  liver  and  kidneys,  more  especially 
the  liver.  In  time  the  patient  that  at  first  seemed  to  be  quite 
full-blooded  is  apt  to  become  ansemic,  and  assumes  a  bronzed 
hue,  indicating  an  obscure  toxaemia.  To  guard  against  these, 
I  have  at  the  menstrual  period,  when  the  constitutional  dis- 
turbances are  most  marked,  generally  employed  bromide, 
twenty  to  thirty  or  forty  grains,  three  times  a  day,  until  the 
nervous  perturbation  is  relieved.  As  soon  as  the  symptoms 
begin  to  subside  the  bromide  should  be  discontinued  ;  if  there 
is  the  slightest  tendency  to  constipation,  a  saline  laxative  will 
often  give  great  relief.  By  repeating  this  treatment  at  each 
monthly  period,  I  have  been  able  to  carry  some  patients  along 
for  months  or  years  until  the  general  organization  could  be 
taught,  as  it  were,  to  accommodate  itself  to  the  absence  of 
this  important  menstrual  function.  If  the  nervous  and  diges- 
tive symptoms  continue  between  the  menstrual  periods,  treat- 
ment should  be  kept  up,  smaller  doses  of  bromide  being 
given,  and  the  bowels  kept  free.  Should  the  kidneys  be  in- 
active, as  they  sometimes  are,  diuretics  may  be  given.  Ac- 
tive, wholesome  mental  and  physical  occupation  is  of  impor- 
tance and  value,  the  object  being  to  occupy  the  vital  forces  so 
as  to  leave  less  supplemental  nutrition  for  purpo3es  of  men- 
struation.    Diet  should  also  be  attended  to.     While  I  have 


DERANGEMENTS  OP  MENSTRUATION.  53 

never  believed  that  the  human  race  ought  to  be  vegetarians, 
I  am  perfectly  well  satisfied  that  these  imperfect  women 
do  very  much  better  on  a  vegetable  diet,  or  at  least  a  diet 
that  includes  very  little  animal  food.  Milk,  eggs,  and  fish 
may  be  eaten,  but  not  much  of  the  latter.  Social  condi- 
tions should  be  directed  as  far  as  possible.  Such  patients 
are  naturally  inclined  to  society,  but  I  find  that  it  is  unfor- 
tunate for  them  when  they  get  sufiiciently  interested  in  the 
opposite  sex  to  marry.  I  have  seen  two  who  were  married, 
and  they  suffered  more  and  longer  than  some  others  that  re- 
inained  single. 

I  have  always  believed  that  if  this  tendency  to  menstruate 
persisted,  and  relief  could  not  be  obtained  through  medica- 
tion, the  removal  of  the  ovaries  would  be  justifiable.  It  has 
not  been  my  fortune,  however,  to  see  any  case  where  this 
became  necessary,  although  some  of  my  patients  that  have 
passed  out  of  my  observation  may  have  submitted  to  this 
treatment  without  the  fact  coming  to  my  notice. 

IMPERFECT  MENSTRUATION  FROM   INCOMPLETE  DEVELOP- 
MENT OF  THE  UTERUS. 

The  malformations  of  the  uterus  naturally  divide  them- 
selves into  two  classes :  First,  those  where  the  arrest  of  de- 
velopment occurs  so  early  in  the  process  of  evolution  that  the 
organ  remains  rudimentary  and  entirely  incapable  of  perform- 
ing any  function  ;  and,  secondly,  all  of  those  where  develop- 
ment has  progressed  to  a  point  which  enables  the  uterus  to 
perform  the  function  of  menstruation  in  an  imperfect  way, 
the  degree  of  menstruation  depending  upon  the  extent  of  the 
malformation.  The  first  class  has  just  been  disposed  of.  The 
forms  of  malformation  belonging  to  the  second  class,  which 
is  most  frequently  seen  in  practice,  are  uterus  bicornis  or 
unicornis,  infantile  uterus,  and  the  various  forms  of  flexion  of 
the  uterus.  In  the  malformation  known  as  double  uterus,  or 
uterus  duplex,  the  function  of  menstruation,  in  the  cases  that 
I  have  seen,  was  perfectly  normal,  and  I  have  seen  several 
who  have  borne  children.     The  same  may  be  said  of  uterus 


54  MEDICAL  GYNECOLOGY. 

bicornis,  but,  as  a  rule,  in  this  malformation  the  function  is 
performed  imperfectly.  In  fact,  in  cases  of  uterus  bicornis 
or  unicornis,  and  in  some  cases  of  flexion,  menstruation 
is  usually  short  in  duration  and  often  scant  in  quantity, 
and  in  the  vast  majority  of  cases  attended  with  dysmen- 
orrhcea,  which  either  occurs  at  puberty  or  is  acquired  soon 
thereafter.  The  history  of  those  cases  varies,  of  course,  ac- 
cording to  the  malformation,  and  yet  there  is  a  sameness 
about  all  of  them.  Many  arrive  at  puberty  rather  late 
in  years,  although  some  of  them  may  menstruate  prema- 
turely. Menstruation  in  a  general  way  is  irregular,  the  inter- 
vals between  the  periods  usually  being  too  long.  The  flow 
is  often  scanty  and  of  short  duration,  as  already  stated,  and 
dysmenorrhoea  is  the  rule,  the  character  of  the  pain  being 
rather  acute  and  colicky,  commonly  intermittent  or  remittent, 
located  in  the  uterus,  commencing  twelve  or  twenty-four 
hours  before  the  flow,  and  frequently  relieved  or  arrested 
entirely  when  the  flow  is  fully  established.  If  this  imperfect 
menstruation  continues  for  years,  other  symptoms  are  added 
to  the  dysmenorrhoea,  such  as  backache,  pelvic  tenesmus, 
occasionally  leucorrhoea,  and  nervous  disturbances,  in  the 
form  of  headache,  irritability,  and  weakness  of  the  nervous 
system,  as  shown  by  easily  induced  fatigue.  The  digestive 
organs  are  usually  impaired. 

Causation. — In  regard  to  the  causation  of  uterus  unicornis 
or  bicornis,  little  if  anything  is  known,  as  it  is  an  affection  of 
embryonic  life.  The  persistence  of  the  infantile  uterus  and 
of  the  various  forms  of  flexion  of  the  uterus  is  no  doubt 
caused  by  any  and  all  influences  which  interrupt  the  process 
of  secondary  develojjment  at  puberty.  In  the  preceding  part 
of  this  work  the  conditions  necessary  to  normal  development 
and  the  effects  of  certain  environments  in  arresting  develop- 
ment have  been  treated  of,  so  that  it  is  only  necessary  to 
repeat  that  general  malnutrition,  in  whatever  way  brought 
about,  is  the  chief,  perhaps  the  only,  cause  of  this  arrest  of 
development  at  puberty. 

Treatment. — If  attention  is  called  to  this  class  of  cases 


DERANGEMENTS  OP  MENSTRUATION.  55 

when  they  begin  to  menstruate,  and  to  the  imperfect  way  in 
which  they  perform  this  function,  much  may  be  done  to  aid 
in  completing  this  development,  by  treatment  directed  to 
benefit  the  imperfect  and  painful  menstrual  function.  Of 
course,  the  physician  can  only  reach  the  uterus  through 
general  nutrition,  and  so  everything  that  can  contribute  to 
improving  the  general  health,  and  nutrition  should  be  em- 
ployed. If  insufficient  food  is  taken  because  of  the  loss 
of  appetite,  every  means  should  be  employed  to  persuade  the 
stomach  to  do  its  duty.  The  whole  alimentary  tract  should 
be  brought  into  the  best  condition  by  tonics,  laxatives,  and 
appetizers,  and  if  there  is  anaemia  it  should  be  overcome. 
In  case  the  general  nutrition  appears  to  be  fairly  good,  then 
sufficient  muscular  exercise  should  be  employed  to  stimulate 
the  nutrition  of  the  muscles,  hoping  that  thereby  the  uterus 
which  belongs  in  part  to  the  class  of  muscular  structures  may 
be  improved.  After  this,  exercise  and  postural  treatment 
should  be  advised  ;  the  knee-chest  position  may  be  assumed, 
or  what  is  more  acceiDtable  to  most  young  girls  is  to  rest  on 
the  back  or  sides  with  the  hips  elevated.  Short  periods  of 
rest  should  be  insisted  u]3on  after  each  period  of  active  exer- 
cise.   (See  chapter  on  The  Invalid's  Habit  for  this  in  detail.) 

This  general  plan  of  treatment  should  be  kept  up  as  con- 
tinuously as  possible,  and  attention  also  should  be  directed  to 
giving  relief  during  the  menstrual  period.  If  the  dysmenor- 
rhoea  occurs  in  one  otherwise  in  good  health  and  possessed 
of  a  liberal  blood  supply,  ten  grains  of  bromide  of  soda  and 
three  to  five  grains  of  antipyrine  given  in  cherry-laurel  and 
mint  water,  once  in  two,  three,  or  four  hours,  according  to 
the  necessity,  often  give  most  marked  relief  without  pro- 
ducing the  slightest  ill  effects  afterward.  It  is  well  to  begin 
as  soon  as  the  slightest  pain  is  manifested,  and  with  those 
who  are  very  irregular  as  to  time  I  have  begun  the  use  of 
the  medicine  a  day  before  the  flow  came  on,  the  patient  being 
able  to  foretell  its  approach  by  the  symptoms  characteristic 
of  the  molimen.  In  those  that  are  naturally  of  delicate  con- 
stitution, or  have  been  reduced  from  dysmenorrhcea  having 


56  MEDICAL  GYNECOLOGY. 

continned  for  some  time,  I  have  found  that  the  prescription 
suggested  above  almost  invariably  makes  the  patient  worse. 
Diffusible  stimulants,  on  the  contrary,  then  give  relief.  Aro- 
matic spirits  of  ammonia,  twenty  or  thirty  minims,  five  drops 
of  chloric  ether,  and  five  of  cannabis  Indica,  given  in  sirup 
of  acacia  with  some  aromatic,  such  as  cardamom  or  mint, 
every  three  or  four  hours,  according  to  the  severity  of  the 
suffering,  answer,  as  a  rule,  all  requirements.  I  find  that 
such  are  the  cases  that  derive  relief  from  gin  or  any  alcoholic 
stimulant.  Quinine  and  Warburg's  tincture  have  been  em- 
ployed in  dysmenorrhcea,  and  in  some  of  the  cases  belong- 
ing to  this  class  the  effect  is  quite  beneficial ;  but  such  reme- 
dies are  not  as  agreeable  or  as  efficient  as  the  prescription 
already  given.  I  found  some  patients  who  did  not  take  can- 
nabis Indica  well,  and  I  have  substituted  for  it  moderate  doses 
of  belladonna,  three  to  five  drops  of  the  tincture  every  three 
or  four  hours  with  ammonia  and  ether  ;  when  the  belladonna 
and  cannabis  Indica  are  both  unacceptable,  I  have  used  cam- 
phor. I  have  given  large  doses  of  camphor  water  with  a  little 
ammonia  and  ether  with  marked  effect.  Sometimes  there  is 
so  much  irritability  of  the  stomach  that  it  is  difficult  to 
medicate  at  all ;  then  I  have  used  bromide  and  antipyrine 
by  the  rectum ;  when  this  was  contraindicated  I  have  used 
quinine  in  solution,  and  when  that  proved  insufficient  I  have 
given  the  ammonia  and  chloric  ether  in  siru]D  of  acacia, 
enough  to  prevent  irritation  of  the  rectum,  and  also  to  make 
its  absorption  more  slow.  I  have  also  employed  camphor  in 
this  combination  by  the  rectum,  using  it  by  instillation.  In 
patients  of  a  gouty  or  rheumatic  diathesis  I  have  found  anti- 
pyrine and  salicylate  of  soda,  five  grains  of  each  three  times 
a  day,  given  for  a  day  before  and  during  the  first  day  of  the 
flow,  to  be  of  great  advantage. 

DELAYED  PUBERTY  FROM  CHLOROSIS. 

Chlorotic  girls  mature  slowly  and  menstruate  late  ;  and 
although  there  are  exceptions  to  this  rule,  they  seem  to 
prove  it. 


DERANGEMENTS  OP  MENSTRUATION.  5Y 

Chlorosis  is  a  condition  where  the  vascular  system  is  im- 
perfectly developed.  The  aorta  especially  is  small  and  thin- 
walled,  the  inner  lining  of  the  arteries  sometimes  exhibits 
fatty  degeneration,  and  the  uterus  and  ovaries  are  abnormally 
small.  In  addition  to  their  size  being  abnormal,  the  sexual 
organs  and  the  heart  also  may  be  somewhat  degenerated. 

Chlorotic  blood  has  fewer  red  corpuscles  and  a  smaller 
amount  of  haemoglobin  than  normal  blood. 

The  blood-making  facilities  are  imperfect,  and  Zimmer- 
mann  regaTds  chlorosis  as  in  part  due  to  functional  derange- 
ments of  the  autogenetic  tissues,  so  that  chlorotic  girls  are 
usually  anaemic. 

But  despite  this  anaemia  and  poor  development  of  osseous 
and  muscular  systems,  there  is  a  tendency  to  plumpness,  and 
the  figure  is  well  rounded  from  the  abundant  adipose  and  cel- 
lular tissue. 

The  sclerotic  coat  of  the  eye  is  pearly,  the  face  is  puffy, 
the  mucous  membranes  are  very  pale,  and  the  countenance  is 
waxy,  yellow,  or  yellow-green — the  "green- sickness." 

Menstruation  occurs  at  a  later  age  than  in  normal  girls, 
and  the  flow  is  scanty  and  of  short  duration.  The  intervals 
between  the  periods  are  also  likely  to  be  longer  than  normal. 

Causation. — It  is  clearly  evident  to  my  mind  that  chloro- 
sis generally  arises  from  heredity.  This  opinion  is  based 
upon  the  fact  that  it  usually  manifests  itself  in  infancy. 
While  it  rarely  attracts  attention  until  puberty,  it  begins  at 
the  beginning  of  life.  It  no  doubt  is  true  that  toward  the 
period  of  puberty  and  during  the  secondary  development  of 
the  sexual  organs  the  anaemic  characteristics  of  chlorosis  may 
increase  ;  but  in  every  case  that  I  have  seen  there  was  a  chlo- 
rotic condition  existing  before  the  period  of  puberty.  I  am 
further  sustained  in  this  view  by  the  fact  that  many  years 
ago  I  submitted  the  question  of  chlorosis,  as  seen  among  chil- 
dren, to  Dr.  A.  Jacobi.  I  related  a  case — an  exceedingly 
well-marked  one — that  I  had  seen  in  an  infant,  and  I  found 
that  he  in  his  experience  had  found  the  chlorotic  state  in 
infancy,  and  that  it  continued  throughout  life. 


58  MEDICAL  GYNECOLOGY. 

Yet  if  chlorosis  is  usually  an  inheritance,  it  can  be  greatly- 
aggravated  by  mal-environment  early  in  life,  and  this  has  a 
distinct  bearing  upon  its  management. 

Treatment. — It  is  of  the  greatest  importance  to  detect 
chlorosis  in  early  life,  so  as  to  overcome  the  defects  of  the 
peculiar  organization  before  the  period  of  puberty.  In  chlo- 
rotic  young  girls  there  is  a  dislike  for  active  muscular  exercise. 
They  are  quite  phlegmatic  in  temperament  and  easy-going  in 
disposition.  This  leads  them  to  select  the  life  which  further 
encourages  the  defect  of  development  of  the  circulatory  ap- 
paratus and  favors  the  accumulation  of  adipose  tissue,  so  that, 
as  a  rule,  they  may  be  said  to  be  fat  and  lazy  ;  and  while  they 
are  very  often  mentally  bright  and  of  studious  habits,  these 
characteristics,  nevertheless,  favor  the  imperfections  of  organi- 
zation. Such  children  should  be  encouraged  to  take  a  large 
amount  of  muscular  exercise  of  that  kind  which  favors  the 
development  of  the  heart  muscle  and,  secondly,  the  blood- 
vessels. While  they  are  not  disposed  to  take  exercise  as 
ordinary  children  do,  they  should  be  compelled  to  take  as 
much.  The  diet  should  be  of  a  nature  to  produce  nerve,  bone, 
and  muscle,  and  not  adiiDose  tissue.  The  diet  list  which  we 
usually  give  to  patients  in  adult  life  to  reduce  fat  should  be 
strictly  enforced  upon  chlorotic  children.  Sluggish  action  of 
the  bowels  and  kidneys  should  be  corrected  ;  in  other  words, 
disintegration  and  elimination  should  be  carefully  attended 
to,  and  if  not  maintained  in  a  normal  condition  by  proper 
diet  and  exercise,  medication  should  be  employed.  Consti- 
pation should  be  overcome  by  saline  laxatives  in  case  it  is  due 
to  lack  of  secretion  in  the  alimentary  canal ;  but  should  it 
arise  from  feeble  muscular  action,  belladonna  and  nux  vomica 
in  small  doses  frequently  repeated  are  by  far  the  best  reme- 
dies. It  may  be  necessary,  if  anaemia  persists,  to  give  restor- 
ative tonics. 

The  blood-making  function  must  be  stimulated,  and  I  find 
the  iodide  of  iron — or  iodine  in  some  form  with  iron — to  in- 
crease disintegration,  to  aid  elimination,  and  to  favor  blood 
formation.     I  have  long  used  bichloride  of  mercury  also  in 


DERANGEMENTS  OF  MENSTRUATION.  59 

very  small  doses  with  chloride  of  arsenic  and  iron,  making 
the  doses  correspond  to  the  age  of  the  patient.  By  this 
course  of  treatment  congenital  chlorosis  can  be,  to  a  large 
extent,  overcome  before  the  period  of  puberty.  Unfortu- 
nately, however,  we  do  not  always  see  those  cases  until  they 
become  markedly  anaemic  and  depleted,  because  they  break 
down,  as  it  were,  when  they  come  to  the  period  of  develop- 
ment of  the  sexual  characteristics  ;  in  other  words,  when  they 
come  to  the  secondary  development  of  the  sexual  organs,  not 
possessing,  supplementary  nutrition,  they  are  incapable  of 
taking  up  the  higher  nutrition  of  the  sexual  organs  necessary 
at  puberty,  and  so  they  become  enfeebled  and  more  anaemic, 
and  show  the  characteristics  of  chlorosis  in  a  more  marked 
degree  than  ever.  Under  such  circumstances  it  is  necessary 
to  give  mental  and  physical  rest,  and,  in  place  of  active  mus- 
cular exercise,  to  employ  massage  until  the  nutrition  is  so  far 
improved  that  the  patient  can  take  light  exercise. 

If  they  are  not  able  to  get  ordinary  exercise,  such  as  that 
of  the  child  at  play,  or  if  walking,  horseback  riding,  dancing, 
or  other  healthful  and  interesting  exercise  is  for  some  reason 
impossible,  they  should  take  a  course  in  gymnastics.  In  these 
cases  diet  and  restorative  tonics  claim  marked  attention. 

When  such  chlorotic  patients  attain  puberty,  and  men- 
struation appears,  there  is  often  an  apparent  tendency  toward 
general  improvement.  Menstruation  seems  to  act  favorably, 
nutrition  seems  to  improve,  and  the  anaemia  to  be  slightly 
less  marked.  This  is  the  case  among  those  who  menstruate 
rather  freely.  Occasionally  a  chlorotic  subject  is  found  who 
menstruates  altogether  too  profusely  ;  then,  as  a  rule,  she  be- 
comes worse,  more  weak  and  anaemic.  Dr.  Gerung,  of  St. 
Louis,  has  practiced  arresting  menstruation  in  anaemic  and 
chlorotic  patients,  hoping  by  so  doing  to  relieve  them  from 
this  tax  upon  the  nutritive  forces,  and  thereby  enable  them  to 
gain  strength  more  rapidly.  While  this  may  be  Judicious 
treatment  in  cases  of  menorrhagia  in  chlorotic  women,  I  am 
satisfied  that  it  is  not  so  in  those  who  menstruate  scantily  or 
normally.     In  some  of  the  more  obstinate  cases  the  restor- 


60  MEDICAL  GYNECOLOGY. 

ative  tonics  have  to  be  varied  from  time  to  time.  It  is  often 
necessary  to  give  stomachics  to  induce  an  appetite.  For  this 
purpose  I  have  found  the  elixir  of  pepsin,  bismuth,  and 
strychnine — a  national  formula — to  serve  admirably  ;  a  tea- 
spoonful  before  meals  is  the  dose. 

In  some  very  severe  cases  the  anaemia  is  so  great  that  the 
stomach  is  well-nigh  incapable  of  digestion ;  and  we  know 
the  marked  frequency  of  gastric  ulcer  in  anaemia. 

When  the  digestive  powers  are  at  this  low  point,  small 
quantities — administered  at  short  intervals — of  peptonized 
milk,  beef  peptonoids,  koumiss,  buttermilk,  raw  oysters,  or 
sweetbreads  should  form  the  diet.  These  articles  of  food 
should  be  varied  from  time  to  time,  and  the  drugs  should 
also  be  given  alternately,  neither  arsenic,  strychnine,  iodine, 
nor  iron  being  continued  for  any  great  length  of  time. 

The  cold  bath,  the  cold  pack,  the  cold  sponge-bath — all 
have  had  advocates  as  means  of  relief  for  anaemia  ;  but  care- 
ful observation  tells  me  that  a  sponge- bath  at  a  temperature 
comfortably  borne  by  the  patient  keeps  the  skin  active  and 
produces  all  the  good  results  that  severer  methods  are  said  to 
obtain.  As  the  patients  get  stronger  the  temperature  of  the 
baths  should  be  lowered  in  order  that  a  tonic  effect  should  be 
produced. 

When  general  health  and  the  menstrual  function  are 
brought  as  near  normal  as  possible,  the  diet,  exercise,  and 
mode  of  life  should  be  the  same  as  that  advised  for  chlorotic 
girls  before  puberty  has  arrived  ;  for  this  class  of  patients  be- 
come exceedingly  anaemic  and  suffer  derangements  of  men- 
struation from  the  slightest  overtaxing  or  excess.  In  other 
words,  the  treatment  should  be  continued  after  recovery  from 
the  more  marked  symptoms. 

This  in  brief  brings  the  subject  up  to  maturity— the  estab- 
lishment of  the  primary  function  of  the  sex — i.  e.,  menstrua- 
tion. The  derangements  of  development  and  the  consequent 
disorders  of  menstruation  have  been  noted,  and  this  leads 
up  to  Part  Second,  which  deals  with  woman  in  her  highest 
integrity. 


PAET  II. 

ACTIVE  PERIOD  OF  LIFE,   CHARACTERISTICS  AND 

DISEASES. 

CHAPTER  V. 

SEXUAL   CHARACTEEISTICS  :    STEUCTURAL   DIFFERENCES 
BETWEEN  THE   SEXES. 

The  anatomy  of  the  sexual  organs  of  woman  has  been 
very  minutely  studied  and  described,  and  those  character- 
istics of  her  organization  are  generally  looked  upon  as  the 
differentiating  peculiarities  of  sex.  But  this  view  is  a  very 
limited  one,  for,  in  order  to  have  a  comprehensive  under- 
standing of  woman,  her  whole  organization,  mental  and 
physical,  must  be  fully  taken  into  account.  She  differs  from 
man  in  a  marked  degree  from  sole  to  crown  in  structure, 
nerve  condition,  reactivity  of  organ  upon  organ  and  of  func- 
tion upon  function !  A  clear  appreciation  of  all  the  charac- 
teristics of  sex  is  needed  in  order  to  comprehend  the  diseases 
of  the  sexual  organs,  and  organic  and  functional  derange- 
ments of  the  whole  organization. 

I  propose  to  discuss  somewhat  at  length  the  characteris- 
tics of  woman  and  her  functions  in  so  far  as  they  are  modified 
by  sex.  Considerable  attention  will  also  be  given  to  imper- 
fections of  structure  arising  from  defective  heredity  and  de- 
rangements in  development.  These  may  be  termed  trans- 
mitted imperfections  and  acquired  deficiencies.  The  relations 
of  hygiene  and  therapeutics  to  these  imperfections  of  struc- 
ture (not  necessarily  diseased),  in  regard  to  prevention  on  the 
one  hand  and  correction  or  cure  on  the  other,  will  have  due 

61 


62  MEDICAL  GYNECOLOGY. 

attention.     This  will  be  followed  by  a  consideration  of  func- 
tional diseases,  which  are  very  common  among  women. 

To  describe  a  functional  disease  is  to  define  it.  Suppose 
the  cells  of  a  liver  to  be  tardy  in  their  elaboration  of  waste 
products  and  slow  in  throwing  out  bile  into  an  intestine  ac- 
customed to  the  presence  of  this  secretion.  What  happens  ? 
Dullness  of  mind,  irritability  of  temper,  loss  of  appetite,  con- 
stipation, sallow  skin,  foul  breath,  and  hsemorrhoids.  The 
individual  is  sick  ;  he  knows  it ;  the  physician  knows  it,  rec- 
ognizes the  condition,  quickens  the  functions  by  time-honored 
remedies,  and  all  goes  well.  'Now,  were  sudden  death  to  have 
overtaken  this  bilious  individual,  the  pathologist  could  have 
found  nothing  in  the  liver  at  all  at  variance  with  our  anatom- 
ical notions  of  a  normal  condition  of  that  organ  ;  yet  he  who 
is  a  physiologist  as  well  as  a  physician,  with  eyes  keener  and 
surer  than  a  microscope's  lens,  sees  perversion  of  function 
and  of  function  alone. 

To  give  one  more  instance.  Suppose  a  woman  to  have 
menstruated  regularly  every  fourteen  days,  and  suppose  sup- 
pression to  occur  at  one  period  from  trivial  causes.  This 
suppression  would  entail  all  the  signs  of  metastatic  conges- 
tion. The  woman  would  be  ill,  she  would  be  functionally  ill, 
and,  too,  when,  were  she  Hke  the  majority  of  her  sisters,  she 
would  have  been  in  the  best  of  health  and  spirits. 

The  genital  apparatus  in  the  case  of  a  woman  like  this 
would  be  a  healthy  one  as  far  as  microscopic  examinations 
go.     Her  disturbance  is  functional. 

It  is  the  perversion  of  an  individual's  functions,  from  the 
individual's  own  point  of  view  more  than  from  the  aggregate 
normal,  that  I  would  denominate  a  functional  disease. 

I  am  led  to  believe  that  nerve  influence  upon  the  cells  and 
their  protoplasm  is  the  chief  factor  in  making  them  perform 
normal  work — far  more  so  than  blood  supply.  And  it  is  to 
nerve  influence  that  we  have  to  look  for  the  production  of 
function  changes,  making  the  cells  do  too  much  or  too  little, 
at  the  wrong  time,  or  making  them  do  too  much  or  too  little 
of  some  part  of  their  duty.     And  these  nervous  impulses  are, 


SEXUAL   CHARACTERISTICS.  63 

in  turn,  brouglit  about  either  by  extrinsic  influences,  such,  as 
heat,  cold,  peculiarities  of  the  atmosphere,  or  strong  impres- 
sions made  upon  the  senses  by  profound  silence  and  dark- 
ness, or  extraordinary  noise  and  glaring  light ;  or  they  may 
be  induced  by  mental  emotions  which  derange  the  innerva- 
tion and,  secondly,  modify  the  circulation,  assimilation,  and 
destructive  metamorphosis.  By  far  the  greater  number  of 
functioual  disorders  that  arise  from  deranged  innervation 
have  their  genesis  in  morbid  emotions.  It  is  rarely  that 
intellectual  vs^ork  injures  the  nervous  system,  and  when  it 
does  so  it  is  only  after  having  first  caused  malnutrition  and 
asthenia  or  exhaustion.  In  addition  to  this  we  may  add  that 
any  strong  and  continuous  taxation  of  one  portion  of  the 
body  which  admits  of  decided  inaction  of  the  rest  of  the 
organization  also  leads  to  functional  diseases  ;  and,  finally, 
long- continued  derangement  of  any  function  is  very  liable  to 
lead  to  changes  of  structure  or  to  organic  lesions  beyond  all 
repair. 

Hence  functional  diseases,  pure  and  simple,  are  only  too 
surely  followed  by  anatomical  lesions,  so  that  there  arrives 
the  time  when  "functional  disease"  becomes  a  misnomer  to 
the  precise  mind,  yet  is  all  the  more  applicable  to  him  who 
has  followed  the  logical  sequence  of  events,  and  who  sees 
organic  lesions  as  an  offshoot  of  deep  functional  perversions. 
In  this  age,  when  the  germ  theory  of  disease  is  (deservedly) 
occupying  the  professional  mind  to  a  great  degree,  one  must 
be  careful  not  to  overlook  other  fruitful  sources  of  human 
suffering. 

To  recapitulate  them  in  order — the  conditions  which  are 
essential  to  health  and  upon  which  all  hygienic  and  thera- 
peutic principles  must  be  based — the  general  organization 
must  be  on,  or  nearly  on,  what  is  recognized  as  the  average 
standard  of  required  perfection ;  secondly,  that  in  addition 
to  normal  structure,  so  far  as  size,  consistence,  and  arrange- 
ment are  concerned,  there  must  be  harmony  from  a  well-bal- 
anced state  of  the  organization— that  is,  that  no  portion, 
organ,  or  system  in  the  organization  shall  surpass  the  others 


64  MEDICAL.  GYNECOLOGY. 

in  development  or  function  ;  in  short,  tTiat  a  well-developed, 
healthful  organization  is  the  first  essential,  and  that  this 
shall  be  sustained  by  the  requisite  nutrition  and  healthful 
environments  or  surroundings,  and,  finally,  a  healthful  exer- 
cise of  all  the  functions. 

Starting  from  this  basis,  it  is  necessary  to  consider  fully 
the  predispositions  to  disease  arising  from  peculiarities  of 
organization,  transmitted  imperfections  or  inherited  tenden- 
cies to  disease,  and  then  the  errors  of  hygiene  in  physical 
culture  and  in  general  education  which  tend  to  aggravate 
morbid  states  in  the  delicate  and  sickly,  or  that  may  produce 
those  diseases.  Women  are  predisposed  to  many  diseases 
that  are  unknown  to  the  opposite  sex,  owing  to  the  general 
complexity  of  their  sexual  organs  both  in  structure  and 
function.  Before  puberty  and  after  the  menopause  the  sexes 
are  more  nearly  alike ;  not  nearly  so  dissimilar  in  regard  to 
the  diseases  to  which  they  are  liable.  But  during  the  period 
of  functional  activity  there  are  great  divergencies  which  claim 
the  attention  of  the  physician.  This  is  a  field  ample  enough 
for  observation  and  practice.  Nor  is  it  in  diseases  of  the 
sexual  organs  alone  that  differences  in  the  sexes  are  found. 

A  specialist  in  medicine  must  k:now  more  than  the  part 
he  treats  of.  No  part  of  the  body  should  be  considered  in- 
dependent of  another  in  blood,  nerve,  or  lymphatic  connec- 
tion. 

Further,  there  are  psychological,  moral,  and  mental  pecul- 
iarities that  modify,  if  indeed  they  do  not  cause,  or  cure, 
diseases  in  woman. 

Woman,  owing  to  her  peculiarities  of  structure  and  func- 
tion, not  only  requires  special  hygienic  care,  but  these  pe- 
culiarities so  modify  the  nature  of  diseases  common  to  both 
sexes  as  to  require  special  therapeutic  treatment. 

As  a  basis  for  hygiene  and  therapeutics  it  is  necessary 
that  the  peculiar  characteristics  of  the  sex  in  structure  and 
function  should  be  clearly  understood.  Anatomy  and  physi- 
ology are  the  foundation  of  practical  surgery  and  medicine. 
In  the  past  the  surgeon  has  leaned  most  upon  anatomy  and 


SEXUAL  CHARACTERISTICS.  65 

the  physician  has  been  guided  more  largely  by  physiology  ; 
to-day  both  are  equally  dependent  upon  the  knowledge  of 
structure  for  guidance  in  the  rational  practice  of  all  branches 
of  the  medical  art.  Knowing  this,  is  the  reason  why  I  pro- 
pose to  take  up  the  prominent  features  of  the  structure,  func- 
tions, and  physiology  of  woman  which  have  a  direct  bearing 
upon  the  practice  of  medicine  in  diseases  of  women. 

Within  a  few  years  the  practice  of  medicine  has  made 
great  advances,  not  so  much  in  the  development  and  discovery 
of  new  reriiedies  as  in  combining  many  things  in  the  manage- 
ment of  disease.  Less  reliance  is  placed  upon  drugs  and 
more  upon  hygiene  or  conditions  of  health.  Doctors  give  less 
medicine,  yet  do  more  for  the  sick  than  in  the  past.  In  place 
of  prescribing  medicine  and  giving  directions  about  diet,  the 
medical  attendant  must  see  to  the  sanitary  condition  of  the 
patient's  house — diet,  air  supply,  and  the  kind  of  nursing 
which  includes  watching  the  progress  of  the  disease  from 
hour  to  hour  as  indicated  by  pulse  and  temperature  and  the 
general  condition  of  the  functions  all  and  singularly.  Rest, 
passive  exercise  of  the  body,  and  proper  occupation  of  the 
mind — all  are  sought  to  aid  in  therapeutics. 

The  Osseous  System.— The  skeleton  in  woman  is  noticeable 
in  a  general  way  on  account  of  the  lightness  and  delicacy  of 
the  several  bones,  and  the  fact  that  they  are  smaller  than  in 
man,  except  the  bones  of  the  pelvis,  which  are  large,  but  quite 
smooth,  and  apparently  not  as  strong  as  those  of  the  mascu- 
line pelvis.  The  bones  of  the  chest  are  in  women  relatively 
smaller  than  those  of  the  pelvis  ;  this  determines  her  ovoid 
form,  so  characteristic  of  the  sex.  The  smoothness  and  the 
delicacy  of  the  bones  are  largely  due  to  the  lines  and  pro- 
cesses for  the  insertion  of  muscles  being  less  developed  than 
in  man.     The  grooves  and  fossae  are  also  more  superficial. 

The  Pelvis. — The  pelvis  compared  with  the  rest  of  the  skele- 
ton is  relatively  much  larger.  The  iliac  bones  markedly  di- 
verge above  the  superior  strait,  giving  a  distinct  funnel  shape 
to  this  portion.  The  true  pelvis  is  larger  in  all  its  diameters 
than  the  masculine  pelvis,  and  the  pubic  arch  is  triangular. 


QQ  MEDICAL  GYNECOLOGY. 

The  deptli  of  the  pelvis  from  the  superior  to  the  inferior 
strait  is  not  as  deep  as  in  the  male  ;  tlie  whole  pelvis  lias  a 
noticeable  inclination,  hence  the  symphysis  is  about  three 
inches  lower  than  the  sacro-vertebral  angle.  The  sjDace  occu- 
pied by  the  interarticular  fibro- cartilages  of  the  pelvic  articu- 
lations is  larger,  and  the  joint  between  the  sacrum  and  coccyx 
more  movable.  The  cotyloid  cavities  are  farther  apart  and 
situated  a  little  more  anteriorly  in  relation  to  the  crests  of  the 
ilia.  In  short,  the  pelvis  is  more  capacious  although  not  as 
deep  as  in  the  male,  the  design  evidently  being  to  contain  the 
more  highly  organized  sexual  organs,  and  also  to  form  the 
framework  of  the  parturient  canal.  The  female  pubis  has  the 
form  of  a  saucer  if  we  compare  that  of  the  male  to  the  shape 
of  a  cup. 

The  Extremities.— The  cotyloid  cavities  for  the  reception  of 
the  head  of  the  femur  being  farther  apart  in  women  than  in 
men,  there  follows  a  greater  obliquity  of  the  thigh  bones  from 
above  downward,  so  that  the  knees  appear  to  come  more 
closely  together  than  in  the  male.  In  order  to  maintain  this 
obliquity,  the  neck  of  the  femur  forms  with  the  axis  of  the 
shaft  of  the  bone  a  more  acute  angle  in  women  than  in  men. 
This  width  of  the  pelvis  and  obliquity  of  the  thigh  bones  have 
given  rise  to  the  popular  statement  that  women  are  knock- 
kneed,  and  also  cause  their  peculiar  gait  in  walking  and  run- 
ning. These  characteristics  of  this  portion  of  the  osseous  struc- 
ture, although  not  very  marked,  are  important  as  a  sexual 
difference,  and  add  greatly  to  the  characteristic  form  of  sex. 

There  is  a  marked  sexual  characteristic  in  the  humerus,  in 
the  tortuous  groove  which  extends  from  its  anterior  to  its 
posterior  surface,  and  is  no  doubt  developed  from  a  rotation 
of  the  bone  upon  its  longitudinal  axis.  Following  in  the  side 
of  the  groove  is  an  angle  which  is  called  the  angle  of  torsion. 
This  anatomical  feature  of  the  humerus  is  not  as  well  defined 
in  women  as  it  is  in  men.  It  is  also  an  interesting  fact  that 
it  is  more  marked  in  the  higher  races,  so  that  from  this  point 
of  view  the  humerus  is  not  as  highly  developed  in  women  as 
in  men. 


SEXUAL  CHARACTERISTICS.  6Y 

The  Clavicles  are  straighter  in  women  than  in  men,  and 
relatively  shorter.  This,  taken  in  connection  with  the  fact 
that  the  chest  is  narrower,  makes  the  shoulders  of  women 
more  tapering  as  a  rule. 

The  Cranium. — In  a  general  way  the  head  of  woman  is 
smaller  than  that  of  man,  and  is  much  finer  artistically  in 
outline.  The  mastoid  processes  are  smaller,  the  zygomatic 
arches  are  thinner ;  the  lower  maxillary  bone  is  also  lighter, 
more  slender,  and  its  posterior  angles  more  attenuated.  The 
skull  altogether  is  lighter ;  it  weighs  decidedly  less  than  in 
man,  and  this  difference  is  largely  due  to  the  fact  that  the 
inferior  maxillary  bone  is  relatively  much  lighter  than  the 
others.  The  diameters — antero-posteriorly,  transversely,  and 
vertically — show  a  decided  difference  in  the  sexes.  While  all 
diameters  are  smaller  than  in  men,  the  antero-posterior  is 
relatively  longer,  while  the  vertical  is  shorter.  In  other 
words,  the  cranium  of  the  woman  is  relatively  longer  but  not 
so  high.  This  greater  relative  length  of  the  head  in  woman 
is  due  to  the  comparatively  greater  length  of  the  temporal 
bones. 

The  vertical  diameter  of  the  orbit  is  greater  in  woman 
than  in  man  in  proportion  to  the  transverse  measurement, 
hence  this  cavity  more  nearly  approaches  the  circumference 
of  a  circle,  while  in  man  it  is  oval  in  outline. 

The  Muscular  System. — Muscles  in  women  are,  generally 
speaking,  smaller  than  in  men,  in  a  degree  corresponding  to 
the  osseous  system  in  women  compared  with  men ;  yet  in  this 
respect  their  muscular  system  is  relatively  not  so  much  in- 
ferior to  man's  ;  and,  so  far  as  quality  of  muscular  fiber  is 
concerned,  the  muscles  of  women  are  quite  equal  to  those  of 
men.  One  striking  similarity  of  the  female  sex  is  the  fact 
that  the  central  or  largest  portion  of  the  muscles  of  the  thigh 
is  higher  up — nearer  the  pelvis — than  in  man.  This,  in  con- 
nection with  the  width  of  the  pelvis,  gives  that  tapering  of 
the  limb  so  characteristic  of  the  sex. 

The  Mammary  Glands. — It  might  be  said  that  the  mammary 
glands  are  sexual  organs  peculiar  to  women.    It  is  true  that  in 


68  MEDICAL  GYNECOLOGY. 

the  male  these  glands  are  found,  but  they  are  so  completely 
rudimentary  that  they  may  be  looked  upon  as  merely  the 
remnants  of  embryonic  germs  that  have  been  left  out  in  the 
process  of  development,  so  that  there  is  really  no  comparison 
between  the  mammary  glands  in  the  sexes.  In  women  they 
give  the  most  striking  characteristic  apjDearance,  and  func- 
tionally they  are  of  such  importance  that  they  constitute 
one  of  the  most  prominent  of  sexual  differences. 

Adipose  and  Cellular  Tissue. — In  women  the  adipose  tissue  is 
more  distinctly  abundant  than  in  men.  It  is  possible  also  that 
the  cellular  tissue  is  found  in  greater  abundance,  and  these 
tissues  together  have  a  marked  effect  in  producing  the  general 
appearance  of  women.  It  gives  a  far  more  delicate  outline 
by  covering  up  the  muscles  and  the  bones  which  come  nearest 
the  surface,  thus  giving  the  subtle  outline  with  graceful 
curves  and  general  rotundity  indicative  of  delicacy  and  re- 
finement which  contrasts  in  such  a  decided  degree  with  the 
angularities,  muscular  and  bony  prominences  which  distin- 
guish the  male  and  are  more  indicative  of  strength  than 
beauty. 

The  Skin.— In  women  the  skin  is  finer  in  texture  and  lighter 
in  color  than  in  man  ;  and,  owing  to  the  greater  abundance  of 
subcutaneous  fat,  the  larger  vessels  are  concealed.  This  gives 
a  softness,  delicacy,  and  beauty  which  are  characteristic  of 
the  hair. 

The  Hair. — The  hair  and  its  distribution  over  the  body 
differ  in  a  very  striking  manner  in  the  sex.  It  is  far  more 
abundant  in  man,  not  only  from  his  possessing  a  beard,  but 
also  from  its  growth  upon  the  entire  body.  In  women  of  the 
higher  races  the  beard  is  entirely  absent,  and  the  entire  body 
is  almost  destitute  of  perceptible  hair  except  on  the  pubes, 
where  it  is  quite  as  abundant  in  women  as  in  men ;  but  here 
also  a  marked  difference  prevails  :  in  women  the  hair  of  the 
pubes  terminates  a  little  above  the  mons  veneris,  whereas  in 
the  male  it  extends  up  to  the  umbilicus  in  the  median  line. 

Thorax  and  Abdomen. — The  heart  and  lungs  are  relatively 
smaller  than  in  man.     The  diaphragm  is  smaller  and  has  a 


SEXUAL   CHARACTERISTICS.  69 

greater  convexity.  The  dorsal  groove  is  more  pronounced, 
and  tlie  pit  of  the  stomach  is  higher  because  the  sternum  is 
shorter.  The  lower  end  of  the  sternum  corresponds  with  the 
level  of  the  seventh  dorsal  vertebra,  while  in  man  it  corre- 
sponds with  that  of  the  eleventh.  The  cartilage  of  the  sixth 
rib  is  articulated  with  the  inferior  extremity  of  the  sternum, 
while  in  man  it  is  articulated  with  the  inferior  edge  of  that 
extremity.  The  abdominal  cavity  is  one  inch  higher  than  in 
man,  due  mainly  to  the  construction  of  the  lumbar  vertebrse. 
The  stomach  is  smaller,  somewhat  longer,  but  not  so  broad, 
and  its  muscular  coat  thinner  than  in  man. 

A  line  drawn  from  the  inferior  extremity  of  the  sternum 
to  the  symphysis  pubis  is  parallel  to  the  axis  of  the  body  of 
woman,  while  in  man  it  converges  toward  the  spinal  axis. 

In  woman  the  umbilicus  is  farther  from  the  pubes  than 
from  the  sternum. 

The  bust  is  proportionately  longer  than  man's.  The 
larynx  is  from  one  third  to  one  half  smaller,  its  constituent 
cartilages  thinner,  the  thyroid  is  flatter,  the  glottis  smaller, 
and  the  vocal  cords  shorter.  The  voice  of  woman  differs  es- 
sentially from  the  voice  of  man ;  it  is  one  octave  higher,  be- 
cause her  larynx  is  narrower  and  the  hyoid  bone  is  smaller. 

Organs  of  Special  Sense. — Whether  sex  has  any  influence 
upon  the  development  of  the  organs  of  special  sense  is  still 
a  mooted  question,  and  our  knowledge  concerning  it  is  still 
somewhat  meager.  Experiments  with  reference  to  the  sense 
of  taste  show  that  this  sense  is  better  developed  in  men  than 
in  women. 

Quite  recently  it  has  been  shown  that  the  sense  of  smell  is 
very  much  keener  in  men  than  in  women  ;  much  feebler  dilu- 
tions of  delicate  odors  were  detected  by  men  than  by  women. 

What  has  been  discovered  about  the  sense  of  touch  gives 
thus  far  the  superiority  to  man,    ' 

In  color  discrimination  women  are  ahead  of  men  (Yale 
Psychological  Laboratory). 

In  weight  discrimination  and  in  quickness  of  motor  ability 
men  surpass  women  ;  yet  woman's  endurance  is  greater. 


70  MEDICAL   GYNECOLOGY. 

Sensitiveness  to  Pain. — Prof.  Csesar  Lombroso,  of  the  Univer- 
sity of  Turin,  Italy,  gives  women  credit  for  a  marked  degree 
of  sensory  obtuseness.  He  has  made  very  careful  observa- 
tions, with  all  the  precision  that  characterizes  a  scientific  stu- 
dent's work,  and  concludes  that  women  suffer  less  from  pain 
— both  moral  and  physical — than  men,  because  of  their  less 
sensitive  organization.  He  also  states  his  belief  that  this 
hypothesis  is  the  only  one  that  can  explain  the  greater 
longevity  of  women.  He  endeavors  to  strengthen  his  posi- 
tion by  quoting  the  testimony  of  surgeons  and  dentists  in 
England.  From  these  he  learned  that  women  allowed  them- 
selves to  be  operated  upon  with  astonishing  insensibility  ; 
that  women  underwent  dental  operations  with  more  resigna- 
tion and  calmness  than  men,  and  did  not  swoon  nearly  so  fre- 
quently in  the  dentist's  chair.  That  he  is  right  to  a  certain 
extent  must  be  conceded,  but  in  part,  at  least,  he  is  wrong. 
He  made  his  experiments  on  the  sensory  nerves  of  Italian 
women,  and  in  all  probability  of  the  poorer  classes.  It  is  a 
well-known  fact  that  the  uneducated,  poorer  classes  of  the 
peasantry  in  many  European  countries  are  less  sensitive  than 
men,  because  they  are  less  developed.  It  is  found  that  the 
sensitiveness  of  the  nervous  system  varies  with  the  degree  of 
culture.  The  ability  to  bear  pain  differs  in  different  classes 
of  women  to  as  great  a  degree  as  in  the  different  sexes. 
Take  women  destitute  of  education  and  they  show  less  sen- 
sitiveness. The  difference  in  their  ability  to  bear  pain,  or  to 
desist  from  outcry  under  pain,  is  greatly  increased  in  the 
refined  and  cultivated,  who  have  learned  to  bear  pain.  It 
may  be  briefly  stated  that  the  ignorant  and  undeveloped  are 
not  sensitive,  and  the  highly  refined  and  educated,  who  have 
been  thoroughly  trained  in  life's  duties  and  have  experi- 
enced that  extra  measure  of  pain  to  which  woman  seems  to 
be  doomed  by  reason  of  her  organization  and  functions,  bear 
pain  as  if  they,  too,  were  less  sensitive.  They  have  more 
fortitude  and  more  patience,  but  they  are,  I  believe,  as  sensi- 
tive as  men. 

But  granting  that  the  nerves  of  sensation  are  less  acute 


SEXUAL  CHARACTERISTICS.  71 

in  women  than  in  men  as  a  rule,  it  does  not  by  any  means  fol- 
low that  woman  has  less  moral  or  mental  sensitiveness.  In- 
deed, my  belief  is  the  exact  reverse.  She  certainly  is  quicker 
to  appreciate  any  mental  impression,  pleasant  or  painful. 
From  personal  observation,  women  are  apparently  more  sen- 
sitive to  the  suffering  of  others  than  men. 

In  addition  to  all  the  anatomical  peculiarities  of  women, 
there  are  in  the  higher  tissues  and  tissue  changes  marked 
differences  between  the  sexes. 

To  stat©  this  in  a  technical  way,  it  must  be  said  in  regard 
to  metabolism,  or  tissue  changes,  that  women  are  mainly 
anabolic,  while  men  are  catabolio.  By  this  it  may  be  under- 
stood that  the  tissue  changes,  so  far  as  disintegration  and 
waste  are  concerned,  proceed  more  slowly  in  women,  and  on 
this  account  they  have  the  greater  capacity  for  the  storage  of 
force.  This  may  explain  the  greater  tendency  of  women  to 
the  development  of  adipose  tissue.  It  may  also  account  for 
the  fact  that  they  require  more  sleep  than  men  and  that  they 
bear  very  much  better  the  loss  of  sleep  and  loss  of  blood. 
Their  recuperative  powers  are  greater,  while  their  general 
activity  in  tissue  change  is  somewhat  less. 

Here,  again,  do  we  see  the  subtle  influence  of  the  nerves. 
Metabolism  and  all  metamorphosis  in  the  economy  are  con- 
trolled by  the  nerve  condition,  so  that  "the  faster  we  live, 
the  faster  we  die,"  is  but  too  true. 

The  train  and  nervous  system  differ  from  that  of  the  male 
in  many  very  important  particulars,  and  have  been  the  subject 
of  much  discussion.  A  more  detailed  account  of  the  charac- 
teristics of  her  organization  must  necessarily  be  given  in  order 
to  make  clear  what  is  to  follow. 

Sir  James  Crichton-Browne  *  has  outlined  in  a  very  mas- 
terly and  scientific  way  some  of  the  differences  between  men 
and  women,  especially  in  regard  to  the  brain.  On  this  I 
.quote  the  following : 

"And  first  among  cerebral  differences  between  the  sexes 

*  Oration  delivered  before  the  Medical  Society  of  London,  May  2,  1892. 


72  MEDICAL  GYNECOLOGY. 

I  would  refer  to  mass  and  weiglit — qualities  with  wMcli  one 
almost  insensibly  associates  power  and  strength.  Now,  it  is 
a  matter  of  common  observation  that  women  have  smaller 
heads  than  men,  and  it  is  a  matter  of  scientific  observation 
that  in  all  peojDles  and  races,  without  exception,  the  absolute 
weight  of  the  entire  brain  is,  on  the  average,  greater  in  men 
than  in  women,  though,  of  course,  individual  women  do  some- 
times possess  larger  and  heavier  brains  than  individual  men." 
He  gives  sixteen  hundred  brain  weights  (nine  hundred 
and  forty-five  male  and  six  hundred  and  fifty-five  female) 
and  states  these  results  :  ''The  brains  of  males  exceeded  those 
of  females  in  weight  by  127*68  grammes  (or  4*50  ounces)  on 
the  average,  and,  after  allowing  for  differences  of  stature 
(taking  five  feet  seven  inches  as  the  average  male  height, 
and  five  feet  two  inches  as  the  average  female  height),  there 
is  still  an  excess  of  brain  weight  of  29 '71  grammes  (or  1*05 
ounce)  in  favor  of  the  male.  This  is  a  very  substantial  dif- 
ference, and  if  we  recollect  that  the  brain  of  the  ant — of  the 
mental  powers  of  which  Sir  John  Lubbock  has  spoken  in 
such  complimentary  terms,  declaring  that  they  differ  from 
those  of  man  not  so  much  in  kind  as  in  degree — is  of  the 
size  of  a  pin  point,  we  shall  realize  that  an  extra  ounce  of 
brain  matter  within  the  human  cranium  may  imply  an  enor- 
mous mental  difference.  But  it  is  certain  that  the  actual 
difference  in  brain  weight  between  healthy  Englishmen  and 
Englishwomen  is  much  more  than  one  ounce."  He  makes 
this  last  statement  because  his  observations  were  made  ui)on 
the  brains  of  insane  people,  and  for  reasons  given,  the  obser- 
vations were  made  favorable  to  women,  and  after  adducing 
his  proof — which,  to  say  the  least,  appears  to  have  all  pos- 
sible foundation — he  adds  :  "All  available  evidence  points  to 
the  conclusion  that  the  male  brain  exceeds  in  weight  the 
female  brain  in  this  country  to  an  even  greater  degree  than 
has  hitherto  been  supposed  ;  and  that  the  smaller  size  of  the 
female  brain  is  a  fundamental  sexual  distinction  not  to  be 
accounted  for  by  the  hypothesis  that  environment,  educa- 
tional advantages,  and  habits  of  life,  acting  through  a  long 


SEXUAL   CHAEACTERISTICS.  Y3 

series  of  generations,  have  stimulated  the  growth  of  the  cere- 
brum in  one  sex  more  than  in  the  other,  is  made  clear  by 
the  fact  that  the  same  differences  in  brain  weight  between 
men  and  women  have  been  found  in  savage  races.  And  not 
only  is  the  male  brain  heavier  than  that  of  the  female,  but 
it  has  a  wider  range  of  variation  in  weight.  The  very  big 
brains  and  the  very  small  brains  are  encountered,  just  as 
are  geniuses  and  idiots,  giants  and  dwarfs,  more  frequently 
among  men  than  women. 

"I  have. said  that  an  extra  ounce  of  brain  matter  within 
the  cranium  might  involve  an  enormous  mental  difference. 
It  would  do  this  were  it  generally  and  equally  distributed, 
and  it  would  do  so  in  a  still  more  striking  manner  were  it 
localized  in  a  certain  region  of  the  cerebrum  ;  and  there  are 
grounds  for  believing  that  there  is  a  difference  in  the  balance 
of  parts  in  the  male  and  female  brains  respectively,  and  this 
difference  I  adduce  as  the  second  sexual  difference  between 
them.  Broca — no  mean  authority — has  declared  that  the 
occipital  lobes  are  more  voluminous  in  the  female  than  in 
the  male ;  and  my  own  observations,  published  in  Brain,  in 
1880,  confirm,  as  far  as  they  go,  his  conclusion,  and  show 
that  while  the  frontal  lobes  are  equally  developed  in  both 
sexes,  the  parietal  lobes,  corresponding  roughly  with  the 
motor  area  of  Ferrier,  are  larger  in  the  male  than  in  the 
female,  and  the  occipital  lobes,  certainly  sensory  in  their 
functions,  are  larger  in  the  female  than  the  male. 

"The  third  brain  difference  between  the  sexes  to  which  I 
would  allude  is  one  of  convolutional  arrangement  which  can 
not  yet  be  accurately  defined,  but  which  is  revealed  by  an 
examination  of  a  series  of  photographs  of  brains  of  men  and 
women  that  have  been  stripped  of  their  membranes.  The 
brains  of  women,  like  their  bodies  generally,  are  upon  the 
whole  more  symmetrical  than  those  of  men.  The  difference 
which  I  have  found  in  the  weight  of  the  hemispheres  points 
to  this  conclusion ;  for  in  males  the  right  hemisphere  ex- 
ceeds the  left  in  weight  by  S'T  grammes,  and  in  females  by 
only  2"1   grammes ;   but   pathological   considerations   as   to 


74  MEDICAL  GYNECOLOGY. 

the  regional  distribution  of  wasting  in  organic  diseases  for- 
bid me  to  attach  too  much  importance  to  this  observation, 
and  I  prefer  to  trust  to  mere  ocular  inspection,  which  will, 
I  think,  bring  home  to  any  one  who  diligently  uses  it  the 
superior  symmetry  of  the  female  brain,  due  to  its  compara- 
tive poverty  in  secondary  gyri. 

"It  is  in  the  internal  structure  of  the  brain,  in  the  depth 
and  arrangement  of  its  gray  matter,  in  the  size,  form,  and 
connection  of  the  cortical  cells  in  different  areas,  that,  in  all 
probability,  the  most  essential  differences  between  the  male 
and  female  brain  reside ;  but  the  internal  structure  of  the 
brain  in  this  relation  is  as  yet  uninvestigated."  He  gives 
his  observations  on  this  subject,  and  in  continuation  says: 
"And  not  only  in  the  frontal  region,  but  in  every  convolu- 
tion, the  specific  gravity  of  the  gray  matter  was  lower  in  the 
female  than  in  the  male. 

"And  there  is  still  another — the  fourth — ^brain  difference 
between  men  and  women  which  I  must  submit  to  you,  and 
that  a  very  momentous  one — namely,  vascular  supply.  Dur- 
ing the  last  four  years  Dr.  Sydney  Martin  and  I  have,  as 
opportunity  has  offered,  carried  on  an  inquiry  as  to  the 
size  of  the  great  arteries  that  supply  the  brain.  The  details 
of  our  observations,  which  have  been  conducted  by  Dr. 
Sydney  Martin  with  scrupulous  care  and  by  new  methods, 
insuring,  I  believe,  great  accuracy  of  measurement,  will  be 
communicated  to  the  Royal  Society  when  they  are  complete  ; 
but  I  may  mention  now  one  or  two  of  the  results  at  which 
we  have  arrived.  We  have  found  that  the  diameters  of  the 
internal  carotid  and  vertebral  arteries,  taken  together,  are 
slightly  greater  in  the  male  than  in  the  female.  Their  com- 
bined diameter  is  8*2  millimetres  in  the  male  and  8-0  milli- 
metres in  the  female  ;  but  when  the  difference  between  the 
weight  of  the  male  and  female  brain  is  taken  into  account, 
it  is  found  that  in  proportion  to  brain  weight  their  diameter 
is  greater  in  the  female  than  in  the  male,  and  so  it  appears 
upon  the  whole  that  the  female  brain  receives  a  larger  supply 
of  blood  in  proportion  to  its  mass  than  does  the  male  brain ; 


SEXUAL  CHARACTERISTICS.  Y5 

bat,  of  course,  it  is  to  be  remembered  that  the  blood  going 
to  the  female  brain  is  poorer  in  quality  than  that  going  to 
the  male  brain,  and  contains  only  four  million  five  hundred 
thousand  corpuscles  in  the  cubic  millimetre,  instead  of  five 
million  in  the  case  of  the  male.  But  Dr.  Sydney  Martin 
and  I  have  found  further  that  the  internal  carotid  and  verte- 
bral arteries,  when  measured  separately,  display  a  marked 
difference  in  caliber  in  male  and  female  brains  respectively. 
In  ten  male  brains  of  adults  free  from  brain  disease,  and 
ranging  frota  twenty-five  to  thirty-six  years  of  age,  the  in- 
ternal carotid  arteries  had  an  average  diameter  of  3 '8  milli- 
metres on  the  right  side  and  2 '75  millimetres  on  the  left 
side,  while  the  vertebral  arteries  had  a  diameter  of  2*2  milli- 
metres on  the  right  side  and  1'875  millimetres  on  the  left 
side  ;  whereas  in  ten  female  brains  of  adults  free  from  brain 
disease,  and  ranging  from  twenty-five  to  forty-three  years  of 
age,  the  internal  carotid  arteries  had  an  average  diameter  of 
2*6  millimetres  on  both  sides,  while  the  vertebral  arteries 
had  an  average  diameter  of  2  "3  millimetres  on  the  right  side 
and  of  2 "075  millimetres  on  the  left  side.  It  thus  appears 
that  the  distribution  of  the  blood,  in  the  male  and  female 
brain  respectively,  varies  to  a  considerable  extent.  The 
internal  carotid  arteries,  with  their  great  branches — the  an- 
terior and  middle  cerebral  arteries  supplying  the  supra- 
orbital convolutions  and  island  of  Reil,  the  gyrus  fornicatus, 
the  Rolandic  area,  the  angular  gyrus,  and  the  first  temporo- 
sphenoidal  lobule  —  are  much  larger  both  absolutely  and 
relatively  in  the  male  than  in  the  female  brain ;  but  the 
vertebral  arteries  which  supply  the  occipital  and  temporo- 
sphenoidal  lobules  are  larger  in  the  female  than  in  the  male 
brain,  and  the  basilar  artery,  which  is  practically  a  continu- 
ation of  the  vertebrals,  is  also  larger  in  the  female  brain, 
where  its  average  diameter  is  2  "8  millimetres,  than  in  the 
male  brain,  where  its  average  diameter  is  2*675  millimetres. 
It  might  be  thought  that  the  free  anastomosis  provided  by 
the  circle  of  Willis  renders  comparatively  unimportant  dif- 
ferences of  caliber  in  the  internal  carotid  and  vertebral  arte- 

6 


76  MEDICAL  GYNECOLOGY. 

ries,  and  must  equalize  the  blood  currents  to  the  different 
regions  of  the  cerebrum ;  but  the  fact  is  that  the  posterior 
communicating  arteries — which,  when  dilated  after  the  occur- 
rence of  any  pathological  obstruction  on  the  cardiac  side  of 
the  circle  of  Willis,  maintain  the  circulation  of  the  brain  in 
tolerable  integrity — are  incapable  while  normal,  by  their  cali- 
ber and  position,  of  adjusting  the  balance  between  the  direct 
currents  of  the  carotid  and  vertebral  arteries,  and  it  is  cer- 
tain that  the  result  of  the  difference  of  the  diameter  of  these 
in  the  two  sexes  which  I  have  recorded  is  this :  that  the  an- 
terior region  of  the  brain  is  comparatively  more  copiously 
irrigated  with  blood  in  men,  and  the  posterior  region  in 
women.  And  vascular  supply  is  in  some  degree  a  measure 
of  functional  activity,  the  flow  of  blood  to  an  organ  or  part 
having  always  a  relation  to  its  working  power.  But  the 
region  of  the  brain  which  in  men  is  most  richly  flushed  with 
blood  is  that  which  is  concerned,  we  have  reason  to  believe, 
in  volition,  cognition,  and  ideo-motor  processes ;  while  the 
region  which  in  women  is  most  vascular  is  that  which  is 
mainly  concerned  in  sensory  functions,  and  we  thus  see  that 
there  is  a  relation  between  the  size  of  the  cerebral  arteries, 
and  what  observation  has  taught  us  as  to  the  intellectual  and 
emotional  differences  of  the  sexes. 

"The  structural  differences  between  the  male  and  female 
brain,  which  I  have  briefly  referred  to,  justify  the  conclusion 
that  they  are  organs  broadly  distinguished  from  each  other, 
and  they  have  to  some  extent  different  kinds  of  work  to  do  ; 
and  an  inquiry  into  the  functional  relations  of  each  with 
other  viscera  of  the  body,  did  time  permit  of  it,  would 
strongly  confirm  this  view.  All  through  life  the  male  brain 
differs  from  the  female  in  capacities,  aptitudes,  and  pow- 
ers. All  through  life  there  must  be  a  lack  of  complete, 
unspoken,  unformulated  sympathy  between  the  two  sexes : 
what  is  real  to  woman  is  fanciful  to  man  ;  what  of  moment 
to  her  is  immaterial  to  him ;  a  string  of  detail  in  woman 
becomes  a  wide  generalization  in  man  ;  the  affair  of  the  pres- 
ent obstructs  past  events  of  importance  in  woman  ;  in  man 


SEXUAL  CHARACTERISTICS.  Y7 

the  occurrences  of  yesterday  must  become  the  rule  for  to- 
morrow. These  considerations  appeal  to  all  who  have  to  deal 
with  women  and  their  diseases.  How  infinitely  more  diflBcult 
to  discover  important  symptoms,  to  diagnosticate  conditions, 
and  to  direct  the  great  business  of  cure  in  woman  than  in 
man ! " 

THE   SYMPATHETIC   NERVOUS   SYSTEM  IN  WOMEN. 

So  far  as  my  investigations  have  been  pursued  I  have 
been  able  to  find  very  little  in  works  on  anatomy  showing 
any  special  differentiation  between  this  part  of  the  nervous 
system  in  men  and  women,  excepting  that  the  ganglia  and 
the  connecting  nerve  filaments  are  found  in  greater  abun- 
dance and  more  highly  developed  in  connection  with  the 
pelvic  organs  in  women  than  in  men.  Especially  is  this  the 
case  in  the  gravid  uterus.  I  have,  however,  been  led  to  the 
conclusion  that,  on  the  whole,  the  sympathetic  nervous  sys- 
tem is  more  highly  developed  in  women  than  in  men,  from 
the  fact  that  the  sympathetic  nervous  system  is  most  inti- 
mately connected  with  the  process  of  ultimate  nutrition  ;  and 
since  nutrition  in  relation  to  the  reproductive  organs  of 
women  is  vastly  more  active  and  complex,  especially  during 
gestation  and  lactation,  it  is  reasonable  to  suppose  that  a 
higher  development  of  this  nervous  supply  should  prevail  in 
women  at  all  times.  It  is  also  well  established  that  women 
recuperate  more  rapidly  than  men  ;  their  reproduction  of 
blood  after  haemorrhage  is  certainly  more  rapid  than  it  is  in 
men ;  and  after  exhaustion  they  are  much  sooner  restored 
to  their  former  standard.  Again,  nutrition  is  maintained 
with  greater  activity  to  an  advanced  age  in  women  than  in 
men.  This  possibly  may  be  due  in  part  to  a  superiority  of 
the  sympathetic  system.  While  this  is  not  the  only  ex- 
planation of  the  fact  that  women  are  longer  lived  than  men, 
it  may  be  one  item  which  adds  to  the  greater  prolongation 
of  life  in  women. 

Old  observers  were  certainly  profound  when  they  denomi- 
nated this  "the  sympathetic  system."    And  the  whole  realm 


78  MEDICAL  GYNECOLOGY. 

of  medicine  seems  to  prove  the  higher  organization  of  these 
nerves  in  women  than  in  men. 

Women  oftener  have  a  complication  of  diseases :  a  num- 
ber of  organs — interconnected — all  undergoing  similar  or 
allied  pathological  changes.  Women  also  have  a  larger  num- 
ber of  symptoms  indicative  of  the  existence  of  the  same 
morbid  state  than  men  have  ;  and  these  symptoms  I  have 
found  to  appear  in  a  most  widely  extensive  area.  Chiefly  is 
this  noticeable  in  neuralgic,  gouty,  rheumatic,  and  fibroid 
diatheses. 


CHAPTER  VI. 

GENEEAL   FUlSrCTIOT^AL   CHARACTERISTICS   OF   THE   SEXES. 

In  summing  up  what  has  been  said  of  the  differences, 
mental  and  physical,  between  the  sexes,  it  may  be  stated  in 
general  terms  that  the  great  structural  characteristics  are 
found  in  the  sexual  organs.  The  anatomy  and  physiology  of 
the  sexual  organs  of  women  are  so  fully  discussed  in  works 
upon  those  subjects  that  it  is  unnecessary  to  do  more  than 
mention  the  fact.  In  all  other  respects  there  are  no  essential 
differences  in  the  principles  of  structure  in  men  and  women. 
The  differences  that  have  been  pointed  out  are  simply  modifi- 
cations, which  are  adaptations  to  the  requirements  of  sex. 
All  the  functions  of  the  body  are  alike  in  character,  and  dif- 
fer only  in  degree  of  power  and  activity  ;  and  even  there  the 
difference  is  so  slight  as  to  be  unworthy  of  much  serious  at- 
tention. It  is  again  in  the  function  of  reproduction  that  the 
appreciable  difference  is  noted. 

In  regard  to  the  brain  and  nervous  system— the  subject 
of  much  discussion — the  fact  is  that  all  the  essential  factors, 
the  manifestations  of  which  we  call  mind,  exhibit  no  differ- 
ence in  the  sexes  save  in  degree.  The  anatomists  are  com- 
pelled to  concede  that  the  structure  and  function  of  woman's 
brain  are  the  same  as  man's.  True,  hers  is  a  trifle  smaller 
and  somewhat  less  in  capacity. 

So  far  as  the  intellectual  and  moral  characteristics  are 
concerned,  the  most  unreasonable  opponents  can  only  claim 
that  woman  possesses  these  to  a  lesser  degree  than  man,  but 
is  not  at  all  destitute  of  those  mental  qualities.  There  is 
not  a  function  of  the  brain  that  is  manifested  by  man  that 

79 


80  MEDICAL  GYNECOLOGY. 

is  not  also  performed  by  woman.  There  is  no  essential  men- 
tal element  wanting  in  woman  as  a  member  of  tlie  race.  She 
is  second  to  man  in  originality  of  thought,  will,  Judgment, 
and  reason.  In  all  that  relates  to  the  reproduction  of  the 
species  she  is  mentally  and  physically  superior,  and  is  really 
the  highest  type  of  the  race.  She  is  less  original,  but  is 
more  active,  imitative,  and  in  many  respects  more  executive 
and  responsive. 

MENTAL   OHARACTERISTIOS   OF  WOMAN. 

These  anatomical  peculiarities  which  have  been  briefly 
outlined  lead  us  to  expect  mental  peculiarities  such  as  are 
manifested  by  intellectuality  and  disposition,  and  we  find,  as 
expected,  that  the  mental  characteristics  are  not  only  well  de- 
fined, but  offer  a  marked  contrast  with  that  of  the  male.  Her 
physical  organization  is  not  fully  developed,  and  that  is  why 
she  is  said  to  be  more  like  a  child  in  disposition  and  also 
anatomically.  The  harmony  between  structure  and  function 
obtains  in  woman  as  well  as  all  through  the  animal  kingdom. 
It  has  been  stated  in  a  general  way  that  women  are  less 
intellectual  than  men,  less  original  in  thought,  less  capable 
of  continuity  and  logic  of  thought,  and  hence  they  have 
been  called  more  childlike  in  their  mental  characteristics, 
and  in  this  respect  resemble  rather  the  primitive  races.  The 
difference  in  early  life  is  not  marked,  boys  and  girls  being 
more  nearly  identical  in  their  brain  action  until  the  period 
of  puberty ;  in  fact,  at  this  time  girls  surpass  boys  in  the 
acquisition  of  knowledge,  and  show  a  mental  activity  and 
acuteness  that  are  superior.  After  puberty  woman  does 
not  keep  pace  with  the  companion  of  her  youth  in  this 
regard ;  her  mental  growth  becomes  slower  and  more  lim- 
ited. After  the  menopause  there  is  an  apparent  tendency 
to  become  in  her  mental  qualities  more  like  the  male. 

The  jperceptme  faculty  is  superior  in  acuteness  and 
rapidity,  and  women  acquire  knowledge  quicker,  think  more 
rapidly,  and  remember  better.  Intuition,  so  far  as  it  relates 
to  human  affairs,  is  remarkably  developed  in  women.     Pas- 


GENERAL  FUNCTIONAL  CHARACTERISTICS  OP  THE  SEXES.       81 


^1 


siveness  is  also  a  marked  feature,  and  out  of  this  grows  per- 
haps their  marked  mental  adaptability.  It  is  well  known 
that  women  adapt  themselves  to  the  changing  circumstances 
and  to  their  environments  far  better  and  sooner  than  men  ;  in 
other  words,  they  soon 
adjust  themselves  to 
any  new  order  of  things, 
whether  the  change  of 
environments  be  for 
better  or  'for  worse. 
They  are  much  less 
pugnacious,  and  on 
that  account  far  less 
able  to  meet  and  over- 
come opposition  or  re- 
sistance by  force  in 
whatever  form  they 
may  be  presented.  Al- 
lied to  this  characteris- 
tic is  her  dependence. 
We  often  hear  the  com- 
mon expression  that 
"woman  is  of  a  cling- 
ing nature,"  which  is 
but  another  way  of  ex- 
pressing her  depend- 
ence upon  those  who 
are  her  natural  protect- 
ors ;  and,  beyond  this, 
her  reliance  upon  the  Omnipotent  accounts  for  her  greater 
religious  disposition.  Some  of  the  modern  psychologists 
adopt  the  hypothesis  that  every  being  has  two  minds — an 
objective  and  a  subjective  mind.  If  this  is  the  fact,  then  it 
appears  that  the  objective  mind  is  the  strongest  in  man, 
while  the  subjective  is  equal  or  superior  in  woman. 

She  is  less  egotistical,  so  far  as  the  unpleasant  acceptation 
of  this  word  goes,  but  far  more  of  an  egoist  than  man,  since 


L 


Fiu.  1. 


^""■^ 


Adam  and  Eve,  by  J.  Massey  Rhiiid, 
sculptor. 


82-  MEDICAL   GYXECOLOGY. 

slie  is  a  law  unto  herself,  and  whatever  differs  from  her  ex- 
perience is  the  unreal,  the  new,  the  strange. 

A  woman  may  feel  she  is  wTong,  but  can  not  easily  say 
so  in  words.  AYoman  has  less  pride  than  man  and  more 
vanity  ;  hence  she  is  a  partisan,  a  fact  most  men  should  be 
devoutly  thankful  for. 

Fig.  1  illustrates  in  art  the  sexual  characteristics  de- 
scribed in  the  foregoing  chapter.  j\Ir.  Rhind,  the  distin- 
guished sculptor,  has  given  material  expression  to  the  differ- 
ence in  form,  size,  and  character  of  tissue,  and  the  consequent 
difference  in  the  mental  characteristics.  The  broad  shoul- 
ders, large  bones,  and  muscles  of  the  man,  indicate  strength 
to  struggle  for  existence,  and  his  courageous,  self-reliant 
expression  is  indicative  of  a  corresponding  mental  organiza- 
tion. 

The  wide  pelvis,  large  bust,  smooth,  round,  delicate  limbs 
of  the  woman  show  a  refinement  of  structure  adapted  to  her 
environment.  Her  gentle,  timid,  affectionate  expression  tells 
the  story  of  her  mental  character,  disposition,  and  functions 
in  life. 

SEXUAL   INSTINCT  IN   WOMAN. 

The  sexual  instinct  is  born  at  puberty.  Puberty  simply 
means  the  completion  of  the  development  of  the  sexual 
organs,  through  which  they  attain  a  condition  which  renders 
them  comxDetent  to  perform  their  intended  functions. 

The  sexual  organs  descend  into  the  trae  pelvis,  and  the 
uterus,  while  it  increases  in  size,  is  changed  in  form  from  the 
infantile  to  the  adolescent,  mature  uterus.  It  is  during  this 
time  that  all  sexual  characteristics  which  have  been  dis- 
cussed before  assert  themselves  and  become  apparent,  but 
chiefly  the  sexual  instinct.  This  feeling  is  not  nearly  as 
strong  in  woman  as  in  man.  Indeed,  many  women,  before 
marriage,  are  absolutely  destitute  of  sexual  appetence. 

This  desire  is  apt  to  be  less  strong  in  the  coquettish 
woman  than  in  the  naturally  modest.  After  careful  observa- 
tion of  the  sexes  in  the  married  state  it  is  found  that  sexual 
appetence  is  less  in  women  than  in  men.     Strong  sexual  in- 


GENERAL  FUNCTIONAL  CHAEACTERISTICS  OP  THE  SEXES.       83 

stinct  is  no  assurance  of  fertility,  as  barren  women  may  be 
possessed  of  it.  Indeed,  from  the  history  of  a  great  number 
of  noted  coquettes — French  chiefly,  and  here  is  a  nation  un- 
sparingly, unblushingly  self- scrutinizing,  self-critical — I  am 
sure  the  reverse  is  true,  namely,  that  barrenness  is  oftenest 
associated  with  a  strong  female  sexual  appetence. 

Menstruation  lessens  this  feeling,  but  immediately  before 
the  flow  the  appetence  is  great,  and  immediately  after  its 
cessation  at  its  maximum.  It  is  also  much  more  diminished 
during  lactation  than  during  the  first  six  months  of  preg- 
nancy. 

The  rule  is,  also,  that  the  appetence  diminishes  as  the 
menopause  is  approached,  but  there  are  occasionally  striking 
exceptions  which  are  temporary  or  spasmodic,  and  under  cer- 
tain circumstances  very  unfortunate.  Many  women  marry  in 
whom  the  sexual  instinct  is  absent,  or  very  weak,  influenced 
perhaps  by  social  custom  or  from  a  desire  to  be  independent, 
or  from  Platonic  affection,  and  it  is  believed  that  this  defi- 
ciency is  hereditary,  as  noted  in  their  offspring. 

While  in  the  primitive  races  men  and  women  were  polyg- 
amous, woman  has  been  at  all  times  monogamous  in  dispo- 
sition. And  this  monogamous  instinct  at  once,  to  my  mind, 
elevates  the  quality  of  woman's  thought  or  character  above 
that  in  the  realm  of  the  brute  creation,  places  her  as  man's 
superior  from  the  ethical  point  of  view,  and  makes  the  desire 
of  equality  of  sexes  far  more  necessary  for  man's  advance- 
ment than  for  her  own.  Man  is  still  polygamous  in  dis- 
position, though  less  so  than  in  past  ages,  while  to-day  the 
general  average  of  woman's  sexual  instinct  is  below  that  of 
former  times. 

Woman's  superior  virtue,  purity,  and  refinement  lie  at 
the  foundation,  I  presume,  of  her  faithfulness  and  devotion 
to  all  her  social  duties. 


CHAPTER    yil. 
woMAiSr's  FU]^CTiO]srs  ijst  life. 

A  CAEEFUL  study  of  woman's  organization,  so  far  as  her 
physical  and  mental  structures  are  understood,  enables  one 
to  predict  her  functions,  or  her  sphere  of  activities  and  use- 
fulness, in  this  life.  A  further  clew  to  her  capabilities  may 
be  found  in  observing  what  she  has  been  in  the  past.  Care- 
ful consideration  of  those  occupations  into  which  she  nat- 
urally drifted  by  reason  of  her  organization,  and  of  the  reason 
for  her  existence,  forms  a  basis  upon  which  we  can  construct 
her  present  line  of  action  and  duties.  This  is  the  only  scien- 
tific way  by  which  the  subject  can  be  approached  with  any 
hope  of  arriving  at  correct  conclusions. 

In  the  many  discussions  of  this  subject  which  have  arisen 
in  recent  times,  the  incentives  seem  to  have  been  based 
upon  what  woman  herself  desires  to  be,  guided  by  her  para- 
mount ambition,  and,  on  the  other  hand,  what  men  prefer 
that  she  should  be  and  should  do.  The  only  way  to  se- 
cure for  woman  those  rights  and  privileges  which  alone  can 
secure  for  her  all  prosperity,  and  enable  her  to  become  in 
the  highest  degree  useful  in  life,  is  first  to  learn  what  she  is 
capable  of  doing  and  how  far  she  is  capable  of  advancement 
by  education  and  culture,  so  as  to  enable  her  better  to  per- 
form duties  that  are  assigned  to  her  in  the  present  order  of 
things,  and  to  qualify  her  for  taking  the  higher  stand  and 
engaging  in  different  lines  of  thought  and  action.  This 
appears  to  me  as  the  only  true  way  in  which  to  seek  for  her 
elevation  and  advancement.  When  her  natural  position  in 
this  life  with  all  her  capabilities,  duties,  and  offices  shall  be 

84 


WOMAN'S  FUNCTIONS  IN  LIFE.  85 

defined,  the  way  to  adjust  her  claims  will  certainly  become 
clearer  and  far  more  likely  to  be  accomplished.  As  progress 
is  made  in  this  branch  of  study  it  may  appear  that  certain 
fields  of  action  may  be  broadened  and  extended :  in  other 
directions  they  may  be  contracted  ;  and  it  may  possibly  come 
to  be  known  that  instead  of  changing  her  functions  or  adding 
to  them  to  any  great  extent,  the  greatest  need  may  be  to 
qualify  her  more  fully  for  her  present  occupations.  In  the 
past,  present,  and  future  her  first  and  most  important  func- 
tions relate'  to  the  reproduction  of  the  species,  and  in  this 
she  is  and  ever  must  be  a  superior  type  of  the  race.  In 
all  that  pertains  to  the  position  of  wife,  mother,  and  the 
creator  of  home,  and  in  the  potential  forces  maintaining  it, 
she  is  conceded  to  be  supreme — the  only  one  of  the  human 
family  intended  for  such  a  position  and  capable  of  fulfilling 
it.  These  offices  are  so  well  understood  by  all  who  are 
capable  of  thinking  rationally  that  we  need  not  dwell  upon 
this  part  of  the  subject.  We  may  say,  however,  that  the 
management  of  children  and  young  people  of  both  sexes, 
up  to  the  time  when  they  become  independent  of  parents, 
is  better  accomplished  by  woman  than  man.  Is  there  any 
room  for  question,  then,  as  to  who  ranks  the  higher  in  the 
world— man  or  woman?  While  scientists  show  that  men 
possess  a  little  more  brain,  or  are  larger  physically,  and  pre- 
sent certain  characteristics  which  we  call  manly,  meaning  by 
that,  capability  of  certain  vigorous,  persistent,  coarse  achieve- 
ments, that  man  possesses  more  originality,  and  hence  is  a 
greater  producer  in  the  way  of  thought  and  action  than 
woman,  is  not  that  more  than  counterbalanced,  or  is  it  not 
certainly  equaled,  by  the  yet  higher  office  of  woman  in  pro- 
ducing men  and  women  ?  To  be  the  mother  of  a  worthy  son 
or  daughter  is  surely  as  high  an  honor  as  to  be  the  father  of 
a  new  law,  a  new  theory  in  science,  or  a  new  system  of  tactics 
and  strategy  in  warfare. 

Married,  family  life,  with  its  duties  and  cares,  is,  no 
doubt,  sufficient  to  absorb  most  of  the  time  and  capacities  of 
women  of  average  ability,   yet  there  are  many  avenues  of 


86  MEDICAL  GYNECOLOGY. 

thoTiglit  and  action  leading  out  from  the  home  life,  and  those 
who  are  best  qualified  for  home  life  do  most  outside  its  limits. 
Much  of  the  best  work  that  has  been  done  in  the  world  has 
been  done  by  married  women  who  have  raised  families. 
Their  legitimate  or  most  important  responsibilities  and  duties 
have  not  by  any  means  been  neglected  because  of  their  ac- 
tivities in  other  fields.  In  literature  woman  has  taken  a  very 
high  xDosition.  We  might  give  many  names  and  their  works 
to  show  this,  but  to  those  who  are  at  all  versed  in  the  litera- 
ture of  the  present  time  this  is  unnecessary.  We*  hear  con- 
siderable said  about  how  little  women  have  done  in  literature 
compared  with  what  has  been  done  by  men  ;  that  they  have 
created  but  little,  and  those  who  have  become  distinguished 
were  simply  exceptions  to  the  rule.  This  no  doubt  is  true, 
but  the  exceptions  have  been  so  many  and  so  important  that 
they  sufiiciently  prove  women's  ability  in  this  field  of  intel- 
lectual labor,  and  while  there  have  been  but  few  who  have 
become  distinguished,  the  number  has  been  sufficient  to 
lead  any  one  to  believe  that  they  are  capable  through  edu- 
cation and  culture  of  even  vastly  greater  deeds  in  this  direc- 
tion. In  the  fine  arts,  too,  enough  has  been  accomiDlished 
to  show  that  women,  while  less  creative,  are  more  quick  to 
imitate,  and  well  qualified  in  execution.  While  the  distin- 
guished painters  and  sculptors  are  few,  a  sufficient  number 
have  attained  eminence  to  show  that  they  are  capable  of 
great  things,  and,  what  is  more,  by  proper  qualification  they 
can  be  made  artists  of  a  very  high  order. 

Women's  powers  of  observation,  of  making  nice  and  subtle 
distinctions,  are  far  greater  than  men's,  and  in  art  life  they 
are  apter  pupils  ;  they  know  quicker  than  men  when  they  go 
wrong,  or  strike  the  false  note.  But  they  stop,  finally,  and  men 
do  not,  on  the  upward  road  to  perfection— at  least  what  we  are 
pleased  to  call  perfection.  And  although  they  may  ever  re- 
main inferior  to  the  greatest  of  men,  there  is  no  doubt  that 
they  are  capable  of  becoming  superior  to  the  lesser  lights 
among  the  male  artists.  Again,  in  regard  to  music,  it  has  been 
said  that  woman  has  only  succeeded  in  proving  her  inferiority. 


WOMAN'S  FUNCTIONS  IN  LIFE.  8T 

Rubinstein  and  other  authorities  in  music  have  declared 
that  women  have  no  creative  power  in  this  art.  This  has 
been  so  often  reiterated  that  some  of  the  scientists  have  en- 
deavored to  offer  explanations  of  this  so-called  fact.  It  has 
been  claimed  that  women  have  not  exercised,  and  can  not 
exercise,  any  great  creative  power  in  music.  In  proof  of 
this  it  is  said  that  they  have  had  better  chances  than  boys  in 
obtaining  a  musical  education.  If  there  is  a  branch  of  educa- 
tion in  which  girls  have  been  schooled  to  the  neglect  of  every 
other  it  is  'precisely  that  of  music,  so  says  an  author  in  the 
London  Lancet.  He  also  goes  on  to  say  that  this  is  the  first 
subject  to  which  she  is  put  in  beginning  her  education,  and 
among  the  very  last  she  is  allowed  to  discontinue  ;  that  she 
is  drilled  daily  in  piano-playing,  while  singing  lessons  are 
given  in  the  great  majority  of  cases.  From  this  it  is  inferred 
that  if  education  and  practice  can  develop  her  capabilities, 
she  should  have  excelled  all  male  competitors  in  this  de- 
partment of  education.  Considering  the  time  given  to  this 
branch  of  education,  her  failure  to  evolve  new  harmonies  or 
even  new  melodies  is  one  of  the  most  extraordinary  enig- 
mas in  the  history  of  the  fine  arts.  Certainly  this  would  be 
very  extraordinary  were  it  true.  And  it  is  further  stated  that 
among  the  distinguished  writers — as  Lady  Eastlake  in  her 
celebrated  essay  on  music,  and  by  such  keen  psychological 
analysts  as  Mr.  J.  H.  Lewes,  in  his  Life  of  Goethe — it  is  in- 
deed a  problem  still  demanding  solution. 

This  is  certainly  an  unfair  statement  of  woman's  rela- 
tions to  music.  While  it  is  true  that  we  have  not  had  a 
great  many  composers,  there  certainly  has  been  a  very  large 
number  of  celebrated  performers  and  singers.  We  assuredly 
have  at  the  present  day  among  our  musical  artists  as  many 
celebrated  singers  among  women  as  among  men.  I  doubt 
whether  any  male  singer  has  ever  achieved  the  reputation — 
as  acknowledged  by  artists — of  Madame  Patti.  That  there 
have  not  been  many  great  composers  is  true,  but  that  only 
goes  to  show  that  at  this  stage  of  woman's  mental  evolution 
she  has  not  yet  advanced  as  far  as  man.     Or  may  it  not  be 


88  MEDICAL  GYNECOLOGY. 

that  while  she  is  taught  early  in  life  to  play  and  sing,  she  is 
taught  only  to  play  and  sing  by  those  who  are  unable  to 
impart  the  higher  branches  of  a  musical  education  than  this  ? 
Men  start  out  to  learn  composition  under  teachers  avowedly 
masters  in  developing  musicians  in  the  higher  sense.  The 
composer  requires  to  be  more  than  a  musician  ;  he  has  to 
be  as  much  a  creator  as  the  writer  of  fiction  or  poetry. 
We  certainly  have  had  a  sufficient  number  of  women  com- 
posers of  music — distinguished  ones  at  that — to  show  us  that 
the  germs  are  there  and  simply  want  higher  cultivation. 
Among  these  might  be  mentioned  Miss  G.  A.  Becket,  Paul- 
ine Thys,  the  Princess  of  Saxe,  Am  alia,  Princess  of  Prussia, 
Miss  Bedumesnil,  Maria  Paradies,  Julietta  Folville,  Mrs.  F. 
Jungmann,  Ursula  Asperi,  Lucille  Diaz,  Amelie  J.  Candeille, 
Cecilie  Camiade,  Elisa  Ziliotte,  Mrs.  de  la  Guerre,  Amelie 
Perenet,  Mrs.  Sainte  Croix,  Maria  Agnesi,  Baroness  de  Mais- 
tre,  Donna  Casella,  Viscountess  Grandval,  Miss  Guenin, 
Alma  Rouch,  Hermine  Dejazet,  Elizabeth  Boyd,  Mary  A.  V. 
Gabriel,  Marchioness  Perrier  Pilte,  Teresa  Seneka,  Giulia 
Tirindelli,  Mrs.  Paigne,  Duchess  of  Weimar,  Louisa  A.  Bertin, 
Carolina  Uccelli,  Miss  Collinet,  Mrs.  Louis,  Miss  Duvall,  Miss 
Roche-Jagu,  Delphine  B.  Ugaldi,  Mrs.  Gottenhofer,  Augusta 
M.  A.  Holmes,  Miss  Wulet,  Miss  Caroline  Eugenie  Sourget, 
Margherite  Grimani,  Johanna  Kinkel,  Helena  Munklett, 
Karoline  Wisender,  Suzanne  Lajier,  Mrs.  Walpurga,  Pauline 
Yiardot- Garcia,  Louise  Henriette  Viardot,  Florine  Dezede, 
Mrs.  de  Gail,  Miss  Rivay,  Lucille  Gretry,  Mrs.  Sabatier-Blot, 
Antoinette  Biagoli,  Loisa  Puget,  Miss  de  Kerkado,  Ann  S. 
Mounsey,  Elise  Schmetzer,  Mrs.  H.  de  Yismes,  Miss  Dell' 
Acqua,  Adolf  a  Galleni,  Augusta  Tennstedt,  Miss  Stuart 
Stressa,  Teresa  Guidi-Livnetti,  Margherite  Olagnier,  Mrs.  de 
Sablons,  Carolina  Ferrari,  Mrs.  de  Reynac,  Christine  Mor- 
rison, and  Mrs.  A.  N.  Serow.  These  women  are  said  to  have 
written  one  hundred  and  fifty-three  works  of  an  average  of 
two  acts  each. 

All  this  simply  shows  that  women,  while  they  have  not, 
in  these  departments,  attained  an  equal  standing  with  men, 


WOMAN'S  FUNCTIONS  IN  LIFE.  89 

have  given  complete  evidence  that,  with  time,  education,  and 
culture,  they  can  do  great  work. 

But  to-day  there  is  a  very  large  class  of  women  who,  either 
from  choice,  necessity,  or  compulsion,  are  not  permitted  to 
occupy  the  position  which  they  were  originally  destined  for 
— I  mean  that  large  class  of  women  who  remain  unmarried 
and  hence  have  no  opportunity  of  exercising  their  highest 
functions.  Such  must  be  provided  for,  and  first  of  all  not 
only  those  who  are  dependent  upon  their  own  exertions  for 
support,  but'  those  who  are  provided  for,  yet  must,  if  they 
would  live  natural  and  healthful  lives,  find  occupation  of 
some  kind.  Women  in  the  present  state  of  society  are 
well  qualified  to  engage  in  commercial  pursuits  and  in  the 
mechanical  arts  and  industries ;  the  more  fortunate  who 
have  obtained  a  better  education  are  quite  competent  to 
engage  in  literary  labors  and  in  all  the  arts,  and  they  are 
qualified  for  teachers,  especially  of  the  young  of  both  sexes 
and  of  girls  of  more  mature  age  ;  in  fact,  the  better  class  of 
women  are  infinitely  better  prepared  than  the  inferior  class 
of  men  to  engage  in  nearly  all  occupations.  There  are  a  few 
doors  that  still  remain  closed  against  them,  and  with  some 
reason,  the  legal  and  clerical  professions  most  notably  ;  yet 
I  learn  from  very  recent  and  good  authority  that  there  are 
fifteen  or  twenty  regularly  ordained  women  preachers. 

While  it  has  been  said  that  women  are  by  nature  not 
qualified  to  enter  the  so-called  learned  professions,  I  am  in- 
clined to  believe  that  they  are  so  only  because  they  have  not 
had  the  higher  education  which  is  necessary  to  prepare 
those  who  would  practice  law,  medicine,  or  theology.  In 
some  of  the  rougher  occupations  they  are  entirely  unqualified 
to  engage,  and  I  do  not  believe  that  it  is  possible  by  any 
education  or  culture  to  make  them  ever  capable  of  engaging 
in  them.  Take  military  matters,  for  example,  and  others  less 
objectionable  to  the  female  mind  and  organization,  such  as  a 
mariner's  life,  exploration,  and  others  which  entail  a  great 
deal  of  hardship. 

Yet  many  women  delight  in  accompanying  expeditions, 


90  MEDICAL  GYNECOLOGY. 

either  to  Africa  or  to  the  polar  regions,  that  are  dangerous  ; 
and  they  stand  hardship  well  and  are  most  sympathetic  com- 
panions. 

While  it  is  possible  that  women  may  in  time  become 
equal  to  men  in  their  ability  to  grapple  with  science  and 
to  practice  the  professions  of  law  and  medicine,  I  believe 
that  they  require  to  be  much  modified  by  education  in 
order  to  make  such  occupations  either  successful  with  or 
agreeable  to  them  ;  and  again  it  appears  that  the  ultimate 
result  of  an  education  and  training  that  would  produce  those 
qualifications  must  so  modify  the  whole  character  of  woman 
as  to  probably  render  her  less  competent  for  her  higher 
offices  in  life.  In  fact,  I  doubt  if  such  women  are  the  kind 
that  men  would  like  to  have  or  the  kind  that  women  would 
like  to  be.  This,  however,  is  merely  my  own  opinion  based 
upon  some  thought  and  observation,  and  I  am  possibly 
wrong.  The  only  way  that  that  problem  can  be  solved  with 
certainty  and  with  justice  to  woman  is  to  give  her  every  op- 
portunity to  try.  If  woman  is  really  incompetent  in  this 
direction,  she  will  be  among  the  first  to  discover  it,  and  will 
abandon  such  pursuits  for  those  that  are  more  congenial ; 
but  the  experiment  should  be  tried— in  fact,  is  being  tried 
in  most  of  the  civilized  nations  of  the  earth  at  the  present 
time. 

The  medical  profession  has  shown,  in  this  country  at 
least,  a  disposition  to  admit  women  to  its  ranks  and  to  offer 
opportunities  for  obtaining  professional  educations ;  the  same 
to  a  more  limited  extent  applies  to  the  law.  The  theologians 
are  the  only  ones  who  with  few  exceptions  oppose  the  ad- 
mission of  women  to  their  ranks  ;  this  is  most  extraordinary, 
for  while  there  is  a  reasonable  doubt  as  to  women  being 
qualified  to  become  scientists,  doctors  of  medicine,  or  mem- 
bers of  the  bar,  they  are  certainly  in  their  nature  more  reli- 
gious than  men,  and  by  their  mental  organization  quite  as  com- 
petent to  comprehend  theology,  morals,  and  ethics,  and  also 
to  preach  the  Gospel.  Viewing  the  matter  from  the  stand- 
point of  the  doctor  of  medicine,  and  basing  the  arguments 


WOMAN'S  FUNCTIONS  IN  LIFE.  91 

upon  the  structure  and  function  of  women,  they  can  be  pro- 
nounced capable  of  occupying  the  highest  position  in  the 
Church,  and  in  fact  I  believe  that  to-day  they  do  the  most 
valuable  portion  of  church  v^ork,  and  far  outrank  men  in  per- 
formance of  religious  duties  in  every  way,  except  that  they 
are  not  permitted  to  preach  or  to  receive  remuneration  for 
what  they  do. 


CHAPTER  yill. 

NATURAL   A]SrD   SEXUAL    SELECTION. 

Natnral  selection  (whicli  I  understand  to  be  the  natural 
tendency  of  all  living  beings  to  seek  the  environment  v^hicli 
is  most  agreeable  or  best  suited  to  them)  is  active  in  modi- 
fying character.  That  living  beings  are  endowed  vrith  the 
power  to  seek  for  such  surroundings  as  they  may  require  is 
well  known,  and  is  of  much  importance  in  the  life  of  all. 
It  does  not  follow,  however,  that  among  the  higher  species 
the  best  environment  is  always  sought ;  hence  observers  can 
see  that  mal-environment,  the  result  of  perverted  natural 
selection,  has  its  unfavorable  effect,  and  this  affords  veri- 
table proof  of  the  power  of  natural  selection  in  developing 
the  peculiarities  of  sex.  While  it  is,  perhaps,  the  least  im- 
portant and  the  most  limited  in  influence,  it  is  when  misdi- 
rected capable  of  working  much  evil.  While  the  lower  ani- 
mals act  out  to  the  limit  of  their  natural  inclinations  in  natu- 
ral selection  and  with  a  great  advantage  to  themselves,  it  is 
among  the  human  race  that  we  see  the  most  striking  evi- 
dences of  the  effect  of  the  law  by  observing  the  frequent 
baneful  effects  of  its  violation. 

Natural  selection  is  actively  at  work  in  producing  the 
characters  which  enable  animals  to  live,  but  it  has  also  some 
effect  in  developing  characteristics  of  sex. 

The  discussion  of  sexual  selection  involves  that  of  every 
structural  and  functional  attribute  which  favors  reproduc- 
tion. Woman  is  the  less  qualified  of  the  two  sexes  to  exer- 
cise sexual  selection.  Sexual  instinct,  as  already  stated,  is 
less  developed   in  woman.      In   sexual   selection   the   male 

93 


NATURAL  AND  SEXUAL  SELECTION.  93 

seeks  the  female,  and  all  his  attributes  qualify  him  for  the 
struggle  for  the  female.  The  female  attracts,  and  her  char- 
acteristics are  manifested  in  attractive  features.  He  has 
strength  and  courage  ;  she  has  beauty.  The  exercise  of 
sexual  selection  plays  a  very  important  part  in  evolving 
sexual  characteristics.  When  woman  fails  to  develop  at- 
tractive qualities  she  is  less  likely  to  have  a  chance  to  repro- 
duce her  kind,  and  this  gives  opportunity  to  those  v^ho 
do  have  the  requirements  for  sexual  selection  to  survive  in 
their  offspring.  While  man  is  qualified  to  seek,  win,  and 
defend  the  woman  after  having  won  her,  his  ability  and 
adaptation  to  this  end  are  evolved  from  sexual  selection, 
which  derived  its  primary  impetus  from  his  sex.  Woman, 
on  the  other  hand,  derives  her  characteristics  from  her  ma- 
ternal instinct,  which  is  her  dominating  mental  character- 
istic, and  which  is  the  prime  factor  in  her  sexual  selection. 

Some  evidence  regarding  the  causative  relations  of  sexual 
selection  to  characteristics  is  found  in  the  fact  that  structure 
does  not  favor  reproduction,  although  it  may  enable  one  to 
exercise  natural  selection.  The  opposite  of  this  obtains,  as 
seen  in  the  fact  that  sexual  organs  and  sexual  selection  are 
not  all-sufficient,  nor  do  they  aid  in  maintaining  individual 
life. 

This  is  still  more  evident  from  the  experiment  of  changing 
the  process  of  sexual  selection,  a  thing  that  is  often  done  in 
modern  times.  The  result  is  that  men  are  made  effeminate, 
and  women  become  masculine  in  their  characteristics.  The 
perversion  of  this  natural  law  shows  the  power  that  it  wields 
in  the  production  of  sex  by  its  very  perversion  in  our  time. 

Environment. — The  surroundings  have  a  most  marked  ef- 
fect in  the  development  of  secondary  sexual  characteristics. 
They  act  directly  on  organization,  while  heredity  is  indirect 
in  its  action.  Environment  is  most  important  and  potential 
in  acting  upon  the  mind.  Natural  selection  places  the  be- 
ings in  their  proper  place  in  the  world,  and  the  conditions 
of  life  existing  in  the  environments  have  a  marked  influence 
in    guiding  development  and    growth  and    in   maintaining 


94  MEDICAL  GYNECOLOGY. 

health.  Environments  may  be  either  favorable  or  unfavor- 
able, and  the  effects  or  products  will  be  in  accordance  with 
the  adaptability  or  adaptation  of  environment  and  organiza- 
tion. This  covers  the  ground  in  a  general  way,  but  it  is  also 
essential  to  keep  in  mind  that  normal  environments,  while 
fully  answering  the  requirements  of  one  sex,  may,  to  a  de- 
gree, be  unfavorable  for  the  other.  It  follows  that  there 
must  be  some  modification  of  environment  according  to  the 
sex  in  order  to  effect  the  highest  results.  That  which  is 
adapted  to  the  race  in  general  will  not  be  altogether  suited 
to  both  sexes  alike.  Provision  should  be  made  for  the  sexes 
in  the  environment  in  order  to  have  the  best  results  in  the 
development,  maintenance,  and  reproduction  of  the  race. 
Environment  is  to  some  extent  under  the  control  of  the 
human  race.  Parents  may  choose  the  surroundings  of  their 
children — in  fact,  to  a  certain  extent,  do  create  such  environ- 
ment— and  men  and  women  can  effect  the  same  thing  for 
themselves.  Heredity  and  instinct  direct  natural  selection, 
so  that  each  organization  naturally  seeks  its  proper  environ- 
ment, but  the  mature  can  aid  the  young  in  its  selection  and 
maintenance  in  it.  Throughout  life. each  being  has,  to  some 
extent,  this  matter  of  environment  under  his  own  control. 
Personal  resi^onsibility  enters  here  to  a  large  degree  in  choos- 
ing and  keeping  in  an  agreeable  environment.  It  follows 
also  that  mal-environment  may  be  chosen  by  perverted  will, 
or  from  errors  of  judgment  arising  from  ignorance  or  vice. 
This  may  be  clearly  understood  by  comparing  man's  relations 
to  environment  and  heredity.  The  former  has  a  prevailing 
influence  through  life,  and  is  under  his  own  control  to  some 
extent ;  the  latter  is  limited  to  embryonic  evolution,  and  not 
at  all  under  the  influence  of  the  individual,  and  it  is,  to  a 
limited  extent  (and  indirectly),  under  the  control  of  the  pre- 
ceding generation.  In  its  active  part  in  the  evolution  of  sex, 
environment  is  manifested  by  woman's  devoting  a  large  share 
of  her  life  to  reproduction  and  care  of  the  young.  The  per- 
formance of  these  functions  removes  her  from  out-of-door 
life  and  the  struggle  for  existence.      This  mode  of  life  re- 


NATURAL   AND   SEXUAL   SELECTION.  95 

quires  the  tenderness  of  feeling,  sympathy,  devotion,  pa- 
tience, and  unselfishness  that  are  pre-eminent  among  her 
mental  characteristics.  Sometimes  she  fails  to  develop  the 
strength,  energy,  courage,  and  originality  of  man.  The 
attributes  of  woman  are,  according  to  the  highest  authorities, 
evolved  through  the  influence  of  environments. 

In  the  primitive  races  men  and  v^^omen  are  nearly  alike, 
while  among  civilized  peoples  the  differences  that  are  so 
marked  are  clearly  evolved  through  environment.  Educa- 
tion, which  works  such  great  changes,  is  a  part  of  environ- 
ment, and  thus  plays  an  exceedingly  important  role  in  evolu- 
tion, which  fits  or  unfits  woman  for  her  functions,  preparing 
her  for  her  sphere  in  life  w^hen  her  education  is  of  the  right 
character,  and  unfitting  her  when  based  upon  false  princi- 
ples, or  when  unwisely  carried  out. 

And  now,  concerning  education  as  a  constituent,  integral 
part  of  environment,  it  remains  indisputable  that  while  rational 
education  gives  higher  qualifications  for  woman  in  her  offices 
in  life,  mal-education  deprives  her  of  much  of  her  power.  In 
this  country  the  higher  education  of  girls,  while  enabling 
them  to  enter  into  competition  with  men  in  all  occupations, 
has  rendered  them  less  qualified  for  maternal  duties.  Ac- 
cording to  my  observation,  fewer  women  in  prosperity — 
among  the  educated  classes — marry,  bear  children  and  raise 
them  than  formerly,  and  this  I  attribute  (and  correctly,  I 
trust)  to  improper  education  or  mal-environment,  which  has 
rendered  them  less  willing  to  accept  their  sexual  duties,  and 
less  capable  of  performing  them  when  accepted.  I  must  not 
be  understood  as  opposing  the  education  of  women,  but 
rather  as  objecting  to  faulty  environment,  which  easily  in- 
cludes mal-education.  The  poorer  classes  who  have  to  v/ork 
in  the  fields  and  develop  the  muscular  and  osseous  systems  at 
the  expense  of  the  brain  and  nervous  system  show  a  derange- 
ment from  improper  environment.  This  class,  also,  is  ren- 
dered less  capable  of  performing  the  maternal  functions. 
Among  them  delayed  puberty  and  imperfect  menstruation 
are  often  found.     Those  who  escape  this  suffer  much  when 


96  MEDICAL  GYNECOLOGY. 

they  bear  children.  There  is  a  prevailing  opinion  that  the 
primitive  races  bear  children  with  greater  facility  and  safety 
than  civilized.  This  may  be  so,  but  I  am  confident,  from 
personal  observation  and  from  consultation  with  obstetricians 
of  large  experience,  that  the  women  who  are  overmuscular, 
such  as  field  workers,  are  poorly  qualified  for  the  functions 
of  maternity. 

These  considerations  are  important  in  studying  the  devel- 
opment, health,  and  causative  factors  of  diseases  in  women, 
and  their  influence  is  constantly  at  work  for  good  or  evil. 


CHAPTER   IX. 

PECULIAEITIES    IN    THE    DISEASES    OF   WOMEN    GROWIlSra   OUT 
OF   SEXUAL   CHAEACTEEISTICS. 

To  certain  diseases  woman  has  a  greater  predisposition 
than  man.  The  higher  development  of  the  sexual  organs 
and  their  greater  and  more  varied  functional  activity  both 
render  her  liable  to  many  diseases  which,  in  the  nature  of 
things,  are  impossible  in  man,  and  yet  with  all  this  it  is 
found  that  by  reason  of  her  recuperative  power  and  the  fact 
that  she  enjoys  in  a  marked  degree  a  certain  immunity  from 
many  affections,  she  is  longer-lived— statistics  prove  this — 
although  she  is  doubtless  doomed  to  more  suffering  in  life. 
This  law  holds  good  in  relation  to  sexes  of  the  lower  animals, 
and  also  in  plants.  Although  man  is  possessed  of  greater 
f)hysical  strength,  woman  endures  the  longer,  and  will  bear 
pain  and  suffering  when  the  stronger  sex  would  succumb. 
This  difference  is  observed  in  early  life  ;  more  boys  die  than 
girls,  and  Dr.  Ough  claims  that  from  two  to  six  per  cent 
more  boys  are  born  than  girls,  and  there  are  about  six  per 
cent  more  women  in  the  living  population.  This  is  because 
the  mortality  among  boys  and  men  is  far  greater  than  among 
girls  and  women.  More  men  die  of  zymotic  diseases  than 
women ;  in  fact,  the  mortality  among  women  is  less  in  zy- 
motic, diathetic,  and  all  such  diseases,  except  phthisis  pul- 
monalis,  cancer,  peritonitis,  diphtheria,  and  gallstones. 

In  regard  to  diseases  of  the  nervous  system  the  differ- 
ences observed  in  the  sexes  are  remarkable.  Women  have 
always  been  called  more  nervous  than  men,  and  this  is  true 
to  the  extent  that  they  are  far  more  liable  to  functional  dis- 

97 


98  MEDICAL   GYNECOLOGY. 

eases  of  the  nervous  system,  and  on  account  of  their  greater 
liability  to  contract  bodily  habits  they  suffer  more  from  the 
infective  neuroses.  This  undoubtedly  comes  from  the  fact, 
already  stated,  that  women  are  more  highly  emotional  than 
men,  of  more  active  if  not  broader  imagination,  are  more  imi- 
tative, and  naturally  more  craving  for  sympathy.  Hysteria 
is  included  in  the  functional  disorders  of  the  nervous  system, 
and  in  many  cases  is  induced  by  contagion.  This  tendency 
to  contract  nervous  affections  by  association  vdth  others 
similarly  affected  is  to  some  extent  carried  into  mental 
diseases,  for  it  is  observed  that  women  are  more  injuriously 
affected  by  companionship  with  the  insane  than  men. 
Women,  however,  are  less  liable  to  organic  diseases  of  the 
nervous  system  than  men.  It  has  been  clearly  set  forth  that 
there  is  a  greater  variety  of  organic  diseases  among  men, 
especially  in  those  cases  where  marked  and  grave  anatomical 
lesions  occur.  This  coincides  with  the  facts  described  in  re- 
gard to  mental  and  nervous  conditions  that  are  observed 
among  men  in  the  way  of  extremes,  for  we  know  that 
geniuses  and  idiots  are  more  frequently  found  among  males. 
This  has  been  stated  in  another  way  by  one  authority,  who 
says  that  more  men  than  women  become  insane  ;  while  an- 
other— and  I  think  the  more  accurate  observer  of  the  two — 
says  that  more  women  become  insane,  but  a  large  propor- 
tion of  cases  are  purely  functional  forms  of  insanity,  while 
more  men  die  insane  of  organic  diseases  of  the  brain,  and 
that  in  them  insanity  is  more  frequently  complicated  with 
organic  diseases. 

With  reference  to  the  circulatory  system,  purpura  is  said 
to  be  more  common  among  men  than  women ;  but  this  is  more 
than  counterbalanced  by  the  fact  that  women  suffer  far  more 
frequently  from  chlorosis — in  fact,  chlorosis  among  men  is  ex- 
ceedingly rare,  while  it  is  very  common  among  women  ;  and  if 
we  adopt  the  definition  I  have  already  quoted  from  Virchow 
men  never  can  have  chlorosis.  Carefully  prepared  statisti- 
cal reports  show  that  the  following  maladies  occur  oftener 
in  males  than  in  females  :    Acute  anterior  poliomyelitis  (4 


PECULIARITIES  IN  THE  DISEASES  OP   WOMEN.  99 

to  3),  locomotor  ataxia  (10  to  1),  ataxic  paraplegia,  heredi- 
tary ataxy  (35  to  30),  progressive  muscular  atrophy  (3  to  1), 
pseudo-hypertrophic  muscular  paralysis  (4  to  1),  lisematoma 
of  the  dura  mater  (3  to  1),  acute  cerebral  meningitis,  hydro- 
cephalus, epidemic  cerebrospinal  meningitis  (149  to  106), 
cerebral  haemorrhage,  cerebral  abscess,  infantile  hemiplegia, 
and  until  the  fiftieth  year  of  life  intracranial  tumors. 

The  following  functional  nervous  diseases  are  more  fre- 
quent in  males  than  females  :  Tetany  (7  to  6),  laryngismus 
stridulus  (34'  to  14),  writer's  cramp  (5  to  1),  angina  pectoris, 
infantile  convulsions,  hypochondria  and  saltatoric  spasms, 
while  these  are  met  with  oftener  in  women  than  in  men  ; 
habit  spasm,  spasmodic  torticollis,  epilepsy  (6  to  5),  neuralgia, 
migraine,  exophthalmic  goitre  (5  to  1),  chorea  (3  to  1),  and 
hysteria. 

Males  and  females  are  affected  equally  frequently  with 
primary  spastic  paralysis,  infantile  meningeal  haemorrhage, 
and  cerebral  embolism. 


CHAPTER  X. 

GEISTERAL  THERAPEUTIC  AGEXTS   EMPLOYED  IN  THE  PRACTICE 

OF   GYNECOLOGY. 

Before  proceeding  witli  tlie  consideration  of  those  dis- 
eases wliicli  occur  in  tlie  active  or  middle  x^eriod  of  woman's 
life,  it  is  most  essential  to  give  a  somewhat  detailed  account 
of  those  therapeutic  agents  that  are  not  medicinal,  chief 
among  which  stand  hydrotherapy,  the  Turkish  bath,  massage, 
gymnastic  and  other  movements,  and  electricity. 

The  description  will  be  limited  to  the  valuation  of  them 
in  their  adaptation  and  adaptability  to  the  therapeutics  of 
gynecology. 

It  will  be  found  much  more  convenient  to  obtain  here  a 
general  notion  of  these  agents,  so  that  any  mere  subsequent 
reference  to  the  name  may  suffice  for  its  complete  recall  and 
comprehension. 

HYDROTHERAPY. 

Hydropathic  treatment  has  come  into  great  prominence 
of  late  years,  and  deservedly  so.  Its  value  in  the  treatment 
of  fevers  and  many  other  affections  has  long  been  known, 
but  its  use  in  the  treatment  of  diseases  of  the  nervous  system 
is  of  somewhat  more  recent  date.  The  hygienic  use  of  water 
is,  of  course,  familiar  to  all,  and  has  been  referred  to  already 
in  relation  to  the  management  of  the  young  as  an  aid  to  de- 
velopment and  growth.  I  have  now  to  consider  it  therapeu- 
tically in  relation  to  the  management  of  the  nutritive  and 
nervvous  systems.  It  is  necessary  to  keep  in  mind  the  vari- 
ous remedial  effects  which  can  be  produced  by  the  use  of 
water  in  the  form  of  baths  and  douches  and  the  like. 

100 


AGENTS  EMPLOYED  IN  THE  PRACTICE  OP  GYNECOLOGY.    101 

The  immediate  and  direct  effect  of  almost  all  forms  of 
baths  is  a  certain  impact  or  shock  to  the  cutaneous  nerv- 
ous system.  Remembering  the  highly  organized  structure  of 
the  skin  and  its  extensive  and  abundant  nerve  supply,  it  is 
easy  to  see  how  readily  a  strong  impression  can  be  made  on 
the  whole  organization  by  direct  applications  to  the  skin. 
The  effects  of  water,  of  course,  vary  according  to  the  tem- 
perature and  mode  of  application.  The  chief  effects  are,  first, 
the  stimulating  or  sedative  effect  upon  the  cutaneous  nerves, 
and  the  secondary  effect  upon  the  nerve  centers,  which  may 
be  either  tonic  or  sedative,  according  to  the  use  of  the  agent. 
Action  and  reaction  are  both  obtained.  Mild  stimulation  is 
sometimes  followed  by  sedation,  while  a  sedative  effect  may 
be  followed  by  an  active  reaction.  The  effect  upon  the  circu- 
lation is  of  the  same  order.  The  equalization  of  the  circula- 
tion may  be  obtained  either  by  the  primary  effect  of  a  warm 
bath,  which  will  stimulate  the  capillary  circulation  and  invite 
the  blood  from  the  deeper  structures,  or  the  colder  bath, 
which  may  have  just  the  opposite  effect,  in  first  lowering  the 
circulation  on  the  surface,  increasing  the  heart  action,  and 
driving  the  blood  to  the  deeper  structures,  while  the  reaction 
produces  a  secondary  effect,  the  direct  opposite  of  the  pri- 
mary. This  modification  of  the  circulation  is  not  confined  to 
the  mere  mechanical  heart  action,  but  in  its  ultimate  effect 
favors,  it  is  claimed,  the  blood-making  process.  It  is  prob- 
able, however,  that  this  is  accomplished  directly  through  its 
tonic  effect  upon  the  circulation  and  innervation.  The  tem- 
perature can  be  reduced,  as  is  well  known,  by  the  judicious 
use  of  water.  For  a  long  time  it  has  been  known  that  the 
application  of  cold  in  the  form  of  water  or  ice  lowered  the 
temperature,  but  this  is  often  dangerous.  A  like  result  can 
be  obtained  by  the  use  of  the  warm  or  tepid  bath  in  the  form 
of  the  pack  or  the  ordinary  bath. 

The  first  indication  in  the  treatment  of  neurasthenia  and 
other  nervous  affections  is  to  obtain  the  quieting  or  sedative 
effect  of  the  bath.  This  can  be  accomplished  by  the  use  of 
the  warm  or  hot  pack  at  the  time  when  the  patient  is  too 


102  MEDICAL  GYNECOLOGY. 

irritable  or  weak  to  endure  the  fatigue  of  an  ordinary  bath. 
In  order  to  induce  sleep  the  best  time  for  the  bath  is  just 
before  retiring  for  the  night,  and  before  taking  the  final  dose 
of  medicine  or  the  nourishment  which  may  be  necessary.  In 
those  who  complain  of  itching,  irritation,  and  unpleasant 
feelings  of  the  skin,  with  muscular  twitchings,  a  bath  answers 
very  well.  There  are  some,  however,  who  become  so  excited 
and  nervous  by  the  use  of  the  bath  that  it  drives  away  the 
tendency  to  sleep ;  in  such  cases  the  bath  should  be  used  in 
the  early  part  of  the  day.  After  the  bath  a  brisk  or  gentle 
rubbing,  according  to  the  toleration  and  sensitiveness  of  the 
patient,  is  in  order  ;  and  if  this  does  not  produce  the  desired 
quieting  effect  I  have  had  the  patient  rubbed  with  the  fol- 
lowing inunction  :  Chloral  hydrate  and  camphor,  each  one 
drachm;  cold  cream  (ungt.,  aquae  rosse),  four  ounces.  The 
method  of  giving  the  bath  is  as  follows  : 

The  patient  is  carefully  and  thoroughly  enveloped  in  a 
heavy  woolen  blanket  wrung  out  of  water  at  a  temperature 
of  say  110°  ;  over  this  in  the  same  manner  she  is  envelojDed  in 
another  but  dry  blanket,  and  then  again  in  a  rubber  sheet. 
The  duration  of  this  process  may  be  from  one  half  to  two 
hours. 

The  superficial  vessels  of  the  skin  are  at  once  dilated  by 
the  vapor  that  envelops  the  entire  body  in  this  process,  and 
the  cutaneous  functions  are  excited  to  the  highest  degree. 
The  great  central  viscera  are  relieved  of  pressure,  the  capil- 
lary tension  is  diminished,  and  a  general  bodily  relaxation 
ensues. 

After  the  patient  has  improved  sufficiently  to  endure  the 
tonic  effect  of  the  bath  at  a  lower  temperature  I  employ  the 
following : 

A  coarse  linen  sheet,  or  other  linen  cloth  of  ample  dimen- 
sions, is  dipped  in  water  at  a  temperature,  say,  from  70°  to 
50°,  as  the  case  may  require,  preferably  beginning  with  the 
higher  temperature  and  gradually  reaching  the  lower.  In 
this  sheet  the  patient  is  enveloped  (the  head  also  being  cov- 
ered with  a  wet  napkin  or  toweL,  and  then  wrapped  in  a  dry 


AGENTS  EMPLOYED   IN   THE   PRACTICE   OP   GYNECOLOGY.     103 

blanket,  as  in  the  former  ease.  Cutaneous  constriction  en- 
dures but  a  moment,  and  then  is  very  rapidly  followed  by  a 
flux  of  blood  to  the  entire  surface,  yet  not  much  heat  can 
be  given  off  because  of  the  surrounding  blanket. 

Perspiration  is  not  so  likely  to  be  induced  by  this  as  by 
the  warm  bath. 

This  form  of  bath  is  a  tonic  and  aids  the  general  restora- 
tive treatment  in  a  marked  degree.  Dr.  Baruch,  whom  I 
look  upon  as  the  highest  authority  in  New  York  on  this  sub- 
ject, calls  "attention  to  its  tonic  restorative  effects  as  follows  : 
"Heightened  functional  activity  in  the  nervous  and  muscu- 
lar systems,  and  consequently  increased  nutrition  and  tissue 
change  ;  quiescence  and  subsequent  equalization  of  tempera- 
ture ;  removal  of  fatigue  products ;  reduction  of  functional 
nerve  activity  ;  preparation  in  nerve  and  muscle  for  recuper- 
ative doings,  for,  says  Ranke,  it  is  chiefly  during  (compara- 
tive) inactivity  that  muscle  and  nerve  receive  nutritive  ele- 
ments." 

So  far  I  have  said  nothing  about  the  Turkish  bath,  and 
for  the  reason  that  I  have  generally  looked  upon  the  Turkish 
bath  as  more  of  a  hygieaic  agent,  useful  in  the  treatment  of 
lithsemia  and  excrementitious  plethora,  rheumatic  affections, 
and  so  on.  Again,  neurasthenic  patients  seldom  bear  the 
Turkish  bath  well  if  they  are  markedly  affected.  I  might 
also  refer  here  to  the  shower,  douche,  and  needle  baths,  which 
are  so  efficacious  in  the  treatment  of  hysteria.  They  are  sel- 
dom called  for  in  the  management  of  neurasthenia  unless 
complicated  with  hysteria.  I  mention  these  matters  in  this 
connection  because,  in  order  to  obtain  the  real  benefit  of  hy- 
dropathy, one  must  not  only  comprehend  the  physiological 
and  therapeutic  effect  of  hydropathy,  but  be  able  to  select 
appropriate  treatment  in  certain  affections. 

THE   TURKISH  BATH. 

The  Turkish  bath,  so  called,  is  by  many  regarded  as  an 
auxiliary  measure  to  hydrotherapy,  which  we  have  just 
described.     My  experience  has  been   that  it  is  a  hygienic 


104  MEDICAL  GYNECOLOGY. 

agent  rather  than  a  therapeutic  measure.  Questions  are  far 
more  frequently  put  to  me  regarding  taking  the  Turkish  bath 
as  a  sanitary  luxury  than  I  advise  it  in  the  treatment  of  any 
disease  of  women.  Yet  those  whose  powers  of  elimination 
are  sluggish,  or  whose  skins  are  inactive,  feel  better  for  an 
occasional  Turkish  bath,  and  appear  to  derive  decided  benefit 
from  it  in  the  winter  months. 

Upon  the  sudden  advent  of  cold  weather,  as  we  usually 
have  it  in  this  country,  and  that,  too,  after  a  long  and  hot 
season,  the  system  must  be  shocked  by  and  suffer  from  the 
sudden  suppression  of  accustomed  perspiration  ;  and  this 
change  and  consequent  danger  to  the  kidneys  the  Turkish 
bath  combats.  When  taken  for  such  climatic  reasons  it  may 
be  abandoned  in  midwinter  to  be  resumed  in  the  spring,  when 
it  has  seemed  to  me  to  be  an  excellent  way  of  preparing  for 
the  torrid  heat  that  is  an  accompaniment  of  American  sum- 
mers, at  least  in  this  part  of  the  country. 

Some  can  take  this  form  of  bath  all  the  year  round  and 
be  the  better  for  it,  when  others  would  be  weakened,  or  the 
constant  subjects  of  bronchitis  and  colds.  And  neurasthenic 
patients  have  complained  to  me  of  headache,  faintness,  fa- 
tigue, and  irritability  following  it. 

When  hysteria  appears  in  those  of  the  phlegmatic  tem- 
perament—in the  apathiques—l  have  often  prescribed  the 
Turkish  bath  with  good  results.  Those  who  are  stout  and 
whose  skin  functions  are  not  well  performed  are  the  most 
benefited  thereby.  The  reflex  action  upon  the  peripheral 
nerves  is  in  these  cases  excellent,  and  tissue  metamorphosis 
is  increased. 

The  therapeutic  value  of  the  Turkish  bath  would,  com- 
pared with  other  forms  of  hydrotherapy,  be  much  enhanced 
were  there  an  improved  technique  and  environment.  As 
usually  given,  there  are  many  objections  to  the  Turkish  bath, 
and  some  dangers  that  should  be  guarded  against. 

First,  the  necessary  enforced  restriction  of  ventilation 
oftentimes  diminishes  the  amount  of  benefit  that  might 
have  been  obtained,  especially  in  cases  where  oxygenation 


AGENTS  EMPLOYED  IN"  THE  PRACTICE   OP  GYNECOLOGY.    105 

is    imperative  —  plethora,   gout,   rheumatism,   diabetes,   and 
obesity. 

Unless  great  care  is  taken  on  the  part  of  the  director  and 
attendants  at  the  bath,  exposure  to  contagious  and  infectious 
diseases  is  certain.  My  attention  was  forcibly  called  to  this 
matter  a  number  of  years  ago.  I  ordered  massage  for  one  of 
my  patients,  and  she  employed  the  attendant  from  the  Turk- 
ish bath.  When  this  manipulator  had  finished  treatment 
the  lady  directed  her  to  the  toilet  room  to  wash  her  hands  ; 
to  her  surprise,  the  masseuse  declined  to  wash  her  hands, 
saying  that  it  was  not  worth  the  trouble,  as  she  was  going  to 
give  massage  to  another  case.  This  led  me  to  investigate  the 
subject,  and  I  found  that  while  every  attention  was  given  to 
cleanliness,  as  a  housekeeper  or  laundress  understands  the 
meaning  of  the  term,  there  were  no  efforts  made  to  guard 
against  sepsis  or  contagious  diseases.  These  were  the  facts 
in  regard  to  the  establishments  that  I  investigated :  towels 
were  provided,  but  that  they  had  been  sterilized  was  not 
known.  The  scrubbing  brushes  were  not  cleansed  or  disin- 
fected after  use.  Some  patrons  of  the  bath  take  their  own 
brushes,  but  only  a  very  few  do  so,  and  that  only  recently. 
The  attendants  sometimes,  not  always,  wash  their  hands  after 
treating  each  visitor,  but  I  saw  none  who  made  any  effort  to 
disinfect  or  sterilize  their  hands.  The  blankets  in  which 
patients  recline  after  the  bath  are  used  over  and  over  again. 
The  clean  and  the  unclean  meet  in  the  dressing  and  hot  rooms 
and  in  the  manipulating  rooms,  where  there  is  every  opportu- 
nity to  exchange  compliments  in  the  form  of  disease  germs. 
The  danger  is  apparent  when  it  is  borne  in  mind  that  those 
who  patronize  the  Turkish  bath  establishments  are  often  dis- 
eased, or  come  from  homes  where  contagious  diseases  prevail. 
Extreme  care,  it  is  clearly  evident,  must  be  taken  in  order  to . 
make  this  form  of  bath  a  safe  agent.  Indeed,  in  baths  fre- 
quented by  the  general  public  it  is  almost  impossible  to 
insure  perfect  safety.  A  fair  degree  of  security  could  be 
obtained  by  treating  every  bath  as  an  important  surgical 
operation,  and  taking  all  aseptic  and  antiseptic  precautions 


106  MEDICAL  GYNECOLOGY. 

that  the  surgeon  and  obstetrician  take  in  their  practice. 
This  would  not  only  require  cleanliness  of  the  rooms,  appli- 
ances, and  attendants  in  the  bath,  but  also  a  disinfection  of 
the  patients  and  clothing  of  all  who  come  from  where  there 
are  contagions  and  infections. 

There  should  be  a  room  where  contaminated  patients  could 
be  received,  where  they  could  completely  undress  and  be 
thoroughly  disinfected  by  liberal  scrubbing  in  soap  and 
water,  and,  in  a  word,  treat  the  whole  body  as  a  surgeon 
prepares  his  hands  before  an  operation. 

Meantime  the  patient's  clothing  should  be  thoroughly 
disinfected  in  an  appropriate  sterilizing  room.  If  desired, 
the  patient  might  then,  and  then  only,  enter  the  general 
room  and  feel  that  other  lives  were  not  endangered. 

Suppose  a  mother,  who  has  hovered  about  the  beds  of  her 
boys  dangerously  ill  with  diphtheria  until  convalescence, 
should,  tired  and  worn  out,  jump  into  a  closed  carriage  and 
ride  to  a  near-by  Turkish  bath  to  get  the  calming  and  sopo- 
rific effect  it  leaves  without  consulting  any  one,  since  she  has 
been  used  to  taking  the  baths  as  a  matter  of  course  ? 

What  might  result  ? 

The  reader  can  answer  this,  I  believe,  to  his  entire  satis- 
faction. 

I  do  not  pass  judgment  upon  the  value  of  the  Turkish 
bath  in  many  affections.  I  only  desire  to  call  attention  to  the 
subject  in  connection  with  gynecology.  But  what  I  have 
said  regarding  the  modern  ideas  of  cleanliness  and  guarding 
against  contagion  and  infection  deserves  consideration. 


CHAPTER  XI. 

aElSTEEAL   COlSrSIDEEATIOlSr   OF   ELECTRICITY   IN   THE 
THERAPEUTICS   OF   GYNECOLOGY. 

The  following  discussion  of  central  galvanization,  general 
faradization,  and  static  electricity  is  taken  from  Hare's  Sys- 
tem of  Practical  Therapeutics. 

CENTRAL  GALVANIZATION. 

"Central  galvanization  I  understand  to  be  that  method 
of  treatment  by  which  the  whole  central  nervous  system, 
brain,  sympathetic  nerves,  and  spinal  cord  are  brought  under 
the  influence  of  the  galvanic  current.  To  accomplish  this,  one 
pole,  usually  the  negative,  is  placed  over  the  solar  plexus, 
while  the  other  is  firmly  pressed  on  the  top  of  the  head  and 
gradually  passed  over  the  occiput,  along  the  inner  border  of 
the  sterno-cleido-mastoid  muscle,  from  the  mastoid  fossa  to 
the  sternum,  and  from  the  cilio-siDinal  center  down  the  entire 
length  of  the  spine.  For  this  method,  which  was  first  intro- 
duced and  described  a  number  of  years  since,  is  claimed  a 
distinct  and  important  position.  The  different  applications 
to  the  head  and  neck  which  have  been  variously  used  since 
the  time  of  Remak  are  simply  forms  of  localized  electrization  ; 
but  in  central  galvanization,  as  is  observed,  the  poles  are  so 
placed  that  the  whole  central  nervous  system  is  brought 
under  the  influence  of  one  pole — usually  the  positive — with- 
out disturbing  the  other. 

"  One  reason  that  has  been  offered  for  rejecting  central  gal- 
vanization is  the  fear  that  its  relation  to  electro-physiological 

laws  can  not  be  fully  explained.    It  is  asserted  that  a  remedy, 

8  lor 


108  MEDICAL  GYNECOLOGY. 

in  order  to  be  employed  in  any  special  disease,  must  have 
certain  well-known  physiological  activities  that  directly  meet 
or  counteract  the  observed  pathological  conditions.  To  a 
certain  extent  this  is  true.  For  the  relief  of  a  dry  skin  and 
high  pulse  we  resort  to  diaphoretics  and  arterial  sedatives. 
To  reduce  the  volume  of  blood  in  the  brain  we  have  bromide 
of  potassium  and  chloral  hydrate ;  but,  on  the  other  hand, 
can  any  one  tell  us  minutely  and  satisfactorily  why  iodide  of 
potassium  tends  to  eradicate  the  syphilitic  poison,  or  why 
many  people  are  unmistakably  influenced  by  the  atmospheric 
condition  preceding  a  thunderstorm  ?  Yet  we  have  facts  to 
prove  with  certainty  that  these  are  more  than  coincidences. 
That  we  can  not  accurately  localize  the  action  of  the  current 
to  limited  areas  of  the  brain  has  already  been  stated ;  but 
that  external  applications  of  the  galvanic  current  penetrate 
directly  to  and  appreciably  affect  it  is  thoroughly  established, 
and  the  sedative  and  tonic  effects  that  follow  are  well  known 
to  every  one  who  has  intelligently  and  thoroughly  tested  the 
method. 

"Central  galvanization  demands  afar  greater  familiarity 
with  the  physics  of  the  constant  current,  and  with  both  func- 
tional and  structural  derangements  of  the  central  nervous 
system,  than  is  possessed  by  many  who  essay  its  use.  If 
there  is  any  one  therapeutical  process  in  the  whole  range  of 
practical  medicine  that  more  than  another  defeats  its  own 
legitimate  ends  through  careless  and  ill-directed  or  ignorant 
applications,  it  is  this.  As  a  matter  of  experiment  we  sub- 
mit a  person  in  robust  health  and  with  no  marked  nervous 
susceptibility  to  central  galvanization.  If  the  current  is 
gradually  increased  and  as  gradually  decreased,  without 
interruptions,  few  if  any  unpleasant  sensations  are  induced. 
The  metallic  taste  is  decided,  the  head  experiences  a  sensa- 
tion of  fullness,  and  if  the  experiment  be  prolonged,  or  if 
the  electrodes  be  small,  itching  and  heat  will  be  experi- 
enced at  either  pole,  and  on  the  head  (the  seat  of  the  anode) 
slight  pain  of  a  dull  aching  character  may  possibly  be  felt. 
Another  individual,  however,  of  increased  nervous  suscepti- 


ELECTRICITY  IN  THE  THERAPEUTICS  OP  GYNECOLOGY.    109 

bility  will  experience  an  exaggeration  of  all  these  phe- 
nomena, and  may  subsequently  suffer  from  severe  head- 
ache. Because  of  the  symmetrical  influence  which  the 
galvanic  current,  by  the  method  of  central  galvanization,  ex- 
erts on  the  brain,  little  if  any  dizziness  is  perceived  by  even 
the  most  sensitive  -paUeats.  If,  however,  the  current  be 
passed  transversely  through  the  head,  the  so-called  falsifica- 
tion of  the  muscular  sense  that  results  from  an  unsymmetrical 
stimulation  (one  pole  affecting  the  right  and  the  other  the 
left  hemisphere)  is  the  occasion  of  immediate  and  intense 
vertigo. 

"In  thus  transversely  galvanizing  the  brain  the  hemi- 
spheres are  differently  influenced,  and  the  result  is  a  disturb- 
ance of  the  equilibrium.  In  conditions  of  health  this  dizzi- 
ness, as  a  rule,  passes  off  immediately  on  the  removal  of  the 
electrodes,  and  is  attended  by  no  harmful  results.  In  cer- 
tain pathological  conditions,  however — and  signally  so  when 
such  conditions  are  associated  with  those  peculiarly  impressi- 
ble nervous  organizations  that  are  so  familiar — transverse  gal- 
vanization of  the  brain  is  a  highly  culpable  procedure.  Let 
it  be  clearly  understood,  then,  that  in  most  cases  this  method 
should  be  avoided. 

"  I  might  cite  not  a  few  suggestive  cases,  and  not  solely 
from  my  own  experience,  illustrative  of  the  importance  of 
this  law  ;  but  it  will  suffice,  perhaps,  if  I  simjjly  indicate  a 
few  guiding  propositions.  And,  first,  there  is  a  certain  class 
of  patients,  that  I  have  just  alluded  to  as  being  peculiarly 
impressible,  who  will  in  no  degree  be  benefited  by  passing  the 
current  transversely  through  the  brain ;  on  the  contrary,  if 
there  is  mental  or  physical  derangement  from  any  cause,  such 
application  immediately  aggravates  the  existing  disturbance. 
In  many  instances  there  is  no  outward  indication  of  any  such 
susceptibility,  and  very  frequently  the  most  careful  examina- 
tion will  fail  to  elicit  even  a  suspicion  of  any  unusual  relation 
of  the  nervous  system  to  electrical  stimulation.  It  is  only 
when  these  patients  are  subjected  to  the  test  of  actual  treat- 
ment that  idiosyncrasies  are  manifested  which  would  not  be 


110  MEDICAL  GYNECOLOGY. 

distinctly  revealed  by  any  other  method.  In  two  exceptional 
cases,  for  example,  of  which  I  have  records,  a  current  of  com- 
paratively feeble  tension  caused  an  astonishing  excitation  of 
all  the  nerves  of  special  sense.  Sight,  taste,  smell,  and  hear- 
ing were  perverted  and  exalted  ;  and  that  these  evidences  of 
excitation  were  not  the  result  of  fancy  I  thoroughly  satisfied 
myself  by  unerring  tests.  In  these  cases,  as  in  a  number  of 
others  that  enter  as  factors  into  the  experience  that  guides 
these  observations,  the  after-effects  were  only  less  unpleasant 
than  the  primary,  and  were  disagreeably  persistent. 

"  Now,  observe  the  effects  of  applications  by  the  method  of 
central  galvanization  in  the  same  patients.  The  same  tension 
of  current  caused  a  decided  metallic  taste  (but  no  vertigo  and 
no  ringing  in  the  ears),  with  a  slight  feeling  of  fullness  about 
the  head ;  and  persistence  in  this  form  of  treatment  resulted 
in  decided  relief.  In  consideration,  therefore,  of  these  facts, 
we  should  ever  be  watchful  for  these  susceptible  cases ;  and 
to  avoid  errors  of  judgment  that  might  prove  unfortunate,  we 
should  not  presume  even  on  the  most  extended  experience, 
but  should,  in  the  beginning,  pursue  a  tentative  course. 

"In  the  second  place,  we  have  in  cerebral  effusion  and  sof- 
tening, and  especially  in  cerebral  congestion,  conditions  that 
call  for  care  in  any  method  of  galvanizing  the  nerve  centers. 
In  old  apoplectic  cases  transverse  galvanization  of  the  head 
has  often  been  used  with  no  unpleasant  results.  There  can 
be  no  doubt,  however,  that  it  might  in  many  instances  prove 
exceedingly  hazardous,  and  I  have  even  seen  unmistakable 
evidence  of  the  ill  effects  (dizziness  and  nausea)  of  an  inju- 
dicious application  of  localized  faradization  in  the  neighbor- 
hood of  the  base  of  the  brain  and  in  the  mastoid  fossa.  It 
is  in  cerebral  congestion,  however,  that  we  see  most  clearly 
the  importance  of  rightly  selecting  our  methods  of  electrical 
treatment.  To  give  any  direction  to  the  currents,  excepting 
a  longitudinal  one  (by  which  I  mean  from  the  summit  of  the 
head  downward,  or  from  forehead  to  occiput),  is,  I  believe, 
not  only  unphysiological,  but  contrary  to  the  teachings  of 
extended  and  carefully  recorded  experience. 


ELECTRICITY   IN  THE   THERAPEUTICS  OF   GYNECOLOGY,     m 

"In  this  connection,  and  especially  with  reference  to  cen- 
tral galvanization,  an  exceedingly  important  practical  point 
arises  concerning  polar  influence  and  current  direction.  Is 
the  position  of  the  poles  or  is  the  direction  of  the  current  the 
more  important  factor  in  the  production  of  therapeutical  and 
purely  physiological  efl'ects?  The  French  school,  and  nota- 
bly Legros  and  Onimus,  deny  the  efiicacy  of  polar  influence  in 
exciting  physiological  phenomena,  ascribing  them  chiefly  to 
current  direction.  They  ascribe  anelectro tonic  effects  to  elec- 
trolytic action,  and  to  the  induction  of  currents  of  polarization. 

"The  'contraction  laws'  of  Pfliiger  render  it  quite  possible 
that  in  the  electrical  stimulation  of  a  given  nerve  piece  the 
polar  influence  has  more  to  do  with  the  resultant  physiolog- 
ical effects  than  the  direction  of  the  current ;  and  according 
to  this  theory  the  relative  position  of  the  poles  in  central  gal- 
vanization (anode  above  and  cathode  belov^)  would  seem,  on 
physiological  grounds  alone,  to  be  chiefly  indicated  for  the 
relief  of  symptoms  of  central  origin.  Experience,  at  all 
events,  strongly  confirms  its  propriety. 

"  It  is  very  certain  that  in  many  conditions,  and  especially 
in  true  neuralgise  and  spinal  irritation,  therapeutic  effects 
vary  according  to  the  position  of  the  poles.  In  central  gal- 
vanization few  facts  are  better  established,  to  my  mind,  than 
that  certain  conditions,  such  as  cerebral  congestion  and  forms 
of  hysteria,  may  be  injured  rather  than  benefited  by  what  are 
termed  ascending  currents  ;  but  whether  the  ill  effects  are 
due  to  current  direction  or  polar  action  I  am  not  prepared 
to  say." 

GENERAL  FARADIZATION. 

"In  the  administration  of  general  faradization  we  employ, 
as  is  evident  from  its  nomenclature,  the  faradic  current  alone. 
Its  object  is  to  bring  the  external  portions  of  the  body  (from 
the  head  to  the  feet),  and,  as  far  as  possible,  the  internal 
tissues  and  organs  also,  under  the  influence  of  the  current. 
The  galvanic  current  may  be  used  in  this  way  as  well,  but  it 
is  so  rarely  indicated  that  I  have  not  included  it  in  the  enu- 
meration of  the  methods  of  application.      Its  chemical  and 


112  MEDICAL  GYNECOLOGY. 

reflex  influences  are  so  potent  that,  excepting  in  cases  of  rare 
and  remarkable  insusceptibility  to  influences  of  all  kinds,  its 
effects  would  prove  harmful  rather  than  beneficial.  It  is 
very  seldom  indeed  that  a  case  is  seen  in  which  general  elec- 
trization is  indicated — where,  in  other  words,  the  faradic  cur- 
rent is  not  suflaciently  powerful,  either  directly  or  reflexly, 
to  excite  all  the  physiological  activities, 

"In  order  to  bring  the  whole  body  under  the  influence  of 
the  faradic  current,  the  feet  of  the  patient  should  be  placed 
upon  a  copper  plate,  to  which  the  negative  pole  is  attached. 
The  soles  of  the  feet  are  not  at  all  sensitive  to  the  current ; 
but  if  the  patient  is  especially  nervous  or  susceptible,  the 
feeling  of  constriction  that  is  experienced  in  the  ankles  as 
the  current  passes,  and  the  occasional  contraction  of  the  flex- 
ors and  extensors,  may  become  disagreeable  and  even  hurtful. 
In  this  case  it  will  be  better  to  apply  the  negative  pole  by 
means  of  a  broad  soft  sponge  near  the  coccyx. 

"  The  positive  electrode  may  be  either  natural  or  artificial. 
The  hand  is  the  natural  electrode,  and  those  who  are  able  to 
bear  the  requisite  strength  of  current  through  their  own  per- 
sons, and  are  willing  to  subject  themselves  to  the  fatigue 
which  follows  its  frequent  use  in  this  way,  will  find  it  unri- 
valed by  any  other  form  of  electrode.  It  is  not  absolutely 
necessary  that  the  hand  be  used,  but  it  can  be  readily  under- 
stood that  no  artificial  electrode  that  human  skill  has  devised 
can  equal  the  hand  in  its  flexibility  and  in  the  readiness  and 
completeness  of  its  adaptation  to  every  inequality  of  surface. 
In  all  applications  to  the  head,  eyes,  and  face,  and  in  the 
more  general  treatment  of  acutely  susceptible  patients  and 
hysterical  women,  one  will  fail  in  numberless  ways  to  obtain 
the  same  results  by  using  any  form  of  artificial  electrode. 
Ordinarily,  however,  when  the  axDplications  are  made  along 
the  course  of  the  spine  and  over  the  abdomen  and  lower 
limbs,  the  strength  of  the  current  demanded  is  too  powerful 
to  be  passed  through  the  arms  of  any  operator,  and,  fortu- 
nately, artificial  electrodes  answer  here  as  good  a  purpose  as 
the  hand. 


ELECTRICITY  IN  THE  THERAPEUTICS  OP   GYNECOLOaY.     113 

"In  submitting  a  patient  to  general  faradization  the  oper- 
ation sliould  be  conducted  with  some  regard  to  system.  In 
the  first  place,  the  hair  being  thoroughly  wet,  the  hand  is 
passed  with  firm  pressure  over  the  entire  surface  of  the  head. 
In  treating  the  forehead,  which  is  far  more  sensitive  to  the 
current  than  any  other  portion  of  the  body,  the  operator 
should  first  press  his  moistened  hand  firmly  over  the  part 
and  then  make  the  connection  with  his  other  hand  on  the 
sponge  of  the  sensitive  pole.  The  strength  of  the  current 
when  applied  to  sensitive  parts  of  the  body  can  be  sufiiciently 
regulated  by  increasing  or  decreasing  the  grasp  of  the  posi- 
tive pole  held  by  the  right  hand.  An  application  of  the  fara- 
dic  current  to  the  head  in  many  forms  of  neuralgia,  nervous 
headache,  and  insomnia,  if  properly  given,  is  capable  of 
affording  instant  and  most  grateful  relief. 

"There  are  few,  however,  who  administer  it  with  any  de- 
gree of  precision  or  skill,  and,  as  a  consequence,  we  witness 
aggravation  instead  of  relief  of  pain.  The  slightest  concen- 
tration of  current  in  such  situations  as  the  forehead  is  capa- 
ble of  exciting  pain  even  in  the  normal  condition,  while  a 
proper  diffusion  over  a  broad  surface,  with  equal  and  gentle 
pressure,  affords  a  sensation  as  agreeable  as  it  is  curative. 

"  The  back  part  of  the  head  and  upper  portion  of  the  spine 
(cilio-spinal  center)  will  usually  bear  powerful  applications  ; 
and  it  is  an  interesting  and  important  fact  that  the  applica- 
tions to  this  center  will  produce  far  greater  tonic  effects  than 
when  the  pole  is  applied  to  any  one  other  portion  of  the 
body.  Care  should  be  taken  to  avoid  all  bony  prominences, 
since  slight  currents  in  these  regions  give  pain.  Hence  over 
the  scapula,  clavicle,  sternum,  crest  of  the  ilium,  tibia,  etc., 
care  should  be  exercised  in  the  moderation  of  the  current. 
Let  the  first  applications  be  tentative. 

"  Experience  will  soon  teach  that  there  is  no  remedy  to  the 
effects  of  which  there  is  such  a  varying  degree  of  suscepti- 
bility as  this.  A  glance  will  not  suffice,  and  frequently  care- 
ful examination  will  fail  to  give  information  as  to  the  proper 
strength  and  thoroughness  of  the  treatment  that  should  be 


114:  MEDICAL  GYNECOLOGY. 

first  attempted.  IS'ot  until  the  patient  is  submitted  to  a  care- 
ful electrical  test  can  we  be  sure  that  what  we  might  have 
considered  very  gentle  treatment  will  not  be  too  severe  for 
the  case  in  hand.  As  in  the  administration  of  localized  gal- 
vanization, the  current  may  be  uniform  or  increasing.  When 
the  electrode  is  on  the  head,  cilio-spinal  center,  ei)igastric 
region,  or  when  pressed  firmly  on  the  various  motor  points 
and  nerve  plexuses,  the  current  should  be  increasing.  To 
make  the  applications  successful,  not  only  for  ultimate  good  but 
also  that  the  patient  may  experience  no  subsequent  weariness, 
soreness  of  the  muscles,  or  vague  but  distressing  nervous  feel- 
ings, requires  far  more  care  and  experience  than  is  generally 
supposed.  On  the  part  of  the  operator  are  demanded  a  certain 
degree  of  mechanical  dexterity,  entire  familiarity  with  the 
instrument  required,  a  complete  knowledge  of  electro-thera- 
peutical anatomy,  a  personal  acquaintance  with  the  sensa- 
tions and  behavior  of  all  portions  of  the  body  under  the  dif- 
ferent electrical  currents,  and  close  and  patient  study  of  the 
diseases  and  morbid  conditions  in  which  they  are  indicated. 

"  G-eneral  faradization  is,  to  me,  indispensable  in  the  prac- 
tice of  electro-therapeutics.  Beginning  with  the  method 
many  years  ago,  and  at  first  confining  my  manipulations  in 
electricity  almost  exclusively  to  it,  I  have  not  to  this  day 
een  cause  to  abandon  its  practice.  There  is  no  one  tonics 
infiuence  in  medicine  comparable  to  it  in  power  ;  there  is 
none  to  which  can  be  accorded  such  a  wide  range  of  applica- 
tion. I  can  only  account  for  its  neglect  on  the  part  of  those 
who  profess  proficiency  in  electro-therapeutics  because  of 
the  time  and  labor  requisite  for  its  successful  utilization,  and 
the  unwillingness  of  the  physician  to  subject  himself  or  his 
patient  to  trouble. 

"The  use  of  static  electricity  is  of  very  great  value,  espe- 
cially in  cases  in  which  there  appears  to  be  congestion  of  the 
nerve  centers.  By  first  dry-cupping  the  back  of  the  neck 
and  applying  a  few  mild  shocks  to  the  same  location,  and 
then  finishing  with  the  electric  shower,  as  it  is  sometimes 
called,  over  the  head,  great  relief  is  often  obtained.     In  an 


ELECTRICITY  IN  THE  THERAPEUTICS  OP  GYNECOLOGY.    115 

overworked  brain  that  requires  rest  and  sleep  that  will  not 
voluntarily  come,  this  use  of  electricity  is  of  vast  benefit. 
The  apparatus,  however,  is  not  so  likely  to  be  at  the  com- 
mand of  the  practitioner  as  those  giving  the  ordinary  con- 
tinuous and  faradic  currents." 

STATIC  ELECTRICITY   OR  FRANKLINIZATION. 

"By  franklinization  is  meant  the  application  to  the  body 
of  franklinic  or  static  electricity.  The  simplest  form  of  treat- 
ment is  by  insulation.  By  this  method  the  patient  is  placed 
upon  an  insulating  stool  or  table  and  connected  with  the  con- 
ductors of  either  side,  according  as  a  jDOsitive  or  negative 
charge  is  desired.  This  silent  reception  of  the  electricity 
and  its  silent  and  more  gradual  discharge  from  the  body  to 
the  surrounding  atmosphere  produce  in  most  persons  very 
pleasant  effects.  The  hair  of  the  head  rises  up,  accompanied 
by  an  agreeable  sensation,  as  if  the  wind  were  playing  gently 
around.  The  pulse  may  be  slightly  accelerated  and  the  face 
become  flushed,  while  after  a  time  it  is  occasionally  observed 
that  a  slight  but  general  perspiration  appears.  This  con- 
dition may  frequently  be  kept  up  with  advantage  for  twenty 
minutes  or  so,  until  an  agreeable  feeling  of  drowsiness  is  ex- 
perienced. 

"In  the  treatment  by  sparks  or  spray  the  patient  is  first 
put  in  the  condition  of  insulation  just  described.  Sparks  can 
then  be  drawn  from  any  portion  of  the  body  by  the  near  ap- 
proach of  a  conducting  substance.  Brass  balls  of  various 
sizes,  mounted  on  glass  handles  held  by  the  operator,  con- 
nected by  a  brass  chain  with  the  ground,  or,  better  still,  with 
the  nearest  gas  or  water  pipe,  are  usually  employed.  As  a 
substitute  for  general  faradization,  although  by  no  means  so 
generally  effective  and  far  less  agreeable,  the  metallic  roller 
may  be  used.  It  acts  reflexly  and  excites  the  cutaneous 
nerves  most  decidedly.  When  the  roller  is  used  upon  the 
bare  skin  the  conduction  is  so  perfect  that  no  sensation  is 
appreciated.  It  is  only  when  the  clothing  intervenes  that  the 
peculiar  pricking  sensation  is  observed.      It  is  needless  to 


116  MEDICAL   GYNECOLOGY. 

say  that  to  obtain  the  best  therapeutic  effects  of  the  roller  it 
should  be  applied  over  the  clothing.  The  electric  wind,  so 
called,  following  the  use  of  the  pointed  electrode  is  due  to 
the  agitation  of  the  air  between  it  and  the  person  treated. 
The  discharge  is  silent  and  the  effect  exceedingly  agreeable 
and  refreshing. 

"Treatment  by  Shock. — This  is  a  violent  method  and  not 
usually  called  for.  It  is  produced  by  bringing  the  body,  or 
that  portion  of  it  on  which  we  wish  to  operate,  in  the  circuit 
between  the  outer  and  inner  coating  of  the  Leyden-jar  attach- 
ment. In  addition,  a  static  induction  current,  first  described 
by  Dr.  W.  J.  Morton,  of  New  York,  can  be  obtained.  This 
has  been  suggested  as  a  substitute  for  faradic  electricity.  It 
is  claimed  for  this  current  that  it  produces  maximum  muscu- 
lar contractions  with  a  minimum  amount  of  pain,  and  that 
the  response  is  quicker  than  that  from  the  faradic  current. 
As  for  the  first  claim,  it  is  difficult  to  see  how  it  can  be  de- 
termined, since  the  ordinary  faradic  current,  from  the  single- 
coil  apparatus  especially,  need  seldom  call  forth  pain  in  the 
production  of  muscular  contractions.  The  change  in  the  ap- 
paratus for  the  production  of  this  current  is  quickly  and 
easily  effected,  and  for  the  purposes  of  localized  electrization 
is  most  valuable.  For  general  faradization,  however,  I  can 
quite  confidently  assert  that  it  is  inferior  to  the  current  pro- 
duced by  the  best  faradic  apparatus.  That  it  possesses  cer- 
tain advantages,  however,  over  the  faradic  current  can  not  be 
denied.  Its  voltage  is  enormous,  and  the  alternations  of  each 
spark  (millions  per  second)  so  rapid  as  to  necessarily  give  it 
precedence  in  many  respects  over  the  ordinary  induction 
current. 

"In  order  to  obtain  this  current  it  is  necessary  to  hang  a 
pair  of  Leyden  jars,  as  seen  in  the  illustration,  upon  the 
arms  of  the  machine.  As  the  strength  of  the  current  is 
modified  by  the  size  of  the  jars,  it  is  well  to  have  several  sets 
of  different  sizes.  Rheophores  to  which  ordinary  sponge 
electrodes  are  attached  are  joined  to  the  hooks  that  rest 
upon  the  outer  coating  of   the  jars.      The   strength  of  the 


ELECTRICITY  IN  THE  THERAPEUTICS  OF  GYNECOLOGY.    117 

current  is  in  direct  proportion  to  the  distance  apart  of  the 
two  knobs  of  the  discharging  rods.  These,  therefore,  should 
approximate  closely  at  first,  and  be  separated  gradually  as  a 
stronger  influence  is  desired. 

"The  absolute  value  of  franklinic  electricity  as  a  thera- 
peutic agent  is,  without  question,  very  great.  Its  relative 
value  can  not  be  estimated  with  the  same  readiness,  since 


Fig.  2. 


conclusions  on  this  point  render  it  necessary  to  compare  its 
effects  with  those  of  dynamic  electricity.  Any  arguments, 
therefore,  in  the  direction  of  showing  that  franklinic  elec- 
tricity has  greater  claims  upon  us  as  a  remedy  than  has  been 
generally  believed  must  of  necessity  be  quite  valueless  un- 
less they  are  based  upon  long  and  thorough  use  of  the  dif- 
ferent forms  of  dynamic  electricity,  especially  by  the  methods 
of  general  faradization  and  central  galvanization.  The  diffi- 
culty of  obtaining  reliable  and  exact  information  in  regard  to 
this  matter  will  undoubtedly  lie  in  the  fact  that  in  the  future, 
as  in  the  past,  clinical  reports  will  be  too  often  given  by  those 
who  have  had  no  systematized  or  adequate  experience  in  the 
use  of  dynamic  electricity. 

"  Sedative  and  tonic  effects  of  a  very  interesting  character 
are  undoubtedly  obtained  through  franklinization,  but  these 
effects  are  hardly  equal  in  variety  or  degree  to  those  that 
follow  the  careful  and  thorough  use  of  dynamic  electricity  by 
the  methods  above  mentioned.     None  the  less,  however,  do 


118  MEDICAL  GYNECOLOGY. 

we  hail  the  recent  revival  of  this  neglected  department  of 
electro- therapeutics,  not  only  because  in  certain  conditions  it 
may  possess  some  advantages,  but  because,'  through  peculiar 
idiosyncrasies,  it  is  sometimes  better  borne  than  the  other 
forms.  It  must  not  be  forgotten,  however,  that,  as  a  rule, 
general  faradization  is  far  more  agreeable  than  treatment  by 
sparks,  however  carefully  given.  Those  who  assert  to  the 
contrary  do  so  through  lack  of  exx:)erience  or  skill  in  the  gen- 
eral method  of  administering  faradism. 

"Of  all  the  approved  methods  of  using  electricity,  frank- 
linization has  the  advantage  of  requiring  the  least  skill  and 
experience  in  its  administration,  and  the  disadvantage  of 
necessitating  apparatuses  that  are  cumbersome,  expensive, 
and  not  in  the  same  degree  reliable  as  the  instruments  for  the 
generation  of  dynamic  electricity.  A  still  further  advantage 
lies  in  the  fact  that  little  if  any  disrobing  is  necessary,  since 
the  drawing  of  sparks  and  the  general  stimulation  of  the  sur- 
face are  accomplished  through  ordinary  clothing. 

"Another  important  reason  for  the  use  of  franklinic  elec- 
tricity and  one  which,  to  my  gratification,  I  have  thor- 
oughly tested,  is  its  occasional  value  in  suiDplementing  and 
re-enforcing  the  constitutional  tonic  effects  of  general  fara- 
dization. 

"  It  is  one  of  the  familiar  things  in  medicine  that  a  remedy 
which  at  first  acts  most  effectually  may  after  a  time  cease  to 
have  the  desired  effect.  If  now  we  substitute  a  remedy  of 
the  same  class,  even  though  it  be  inferior,  further  benefit 
often  follows,  and  upon  returning  to  the  original  treatment 
this  again  will  act  with  renewed  vigor.  The  same  principle 
holds  good  in  regard  to  the  dynamic  and  static  forms  of 
electricity.  Occasionally  cases  of  nervous  exhaustion,  as 
well  as  other  forms  of  disease,  after  improving  up  to  a  certain 
point  under  the  influence  of  galvanism  or  faradism,  hang  tire, 
as  it  were  ;  but  by  submitting  the  patient  to  the  action  of 
franklinization  a  new  impulse  seems  to  be  given.  In  this 
way,  one  treatment  supplementing  and  re-enforcing  the  other, 
results  are  obtained  far  more  satisfactory  than  could  possibly 


ELECTRICITY  IN  THE  THERAPEUTICS  OF  GYNECOLOGY.    119 

follow  the  exclusive  use  of  general  or  localized  faradization, 
central  galvanization,  or  franklinization. 

"To  determine  the  exact  status  of  franklinic  electricity  we 
need  still  to  experiment  and  observe.  A  considerable  experi- 
ence, however,  in  its  use  would  lead  me  to  thus  formulate 
what  I  believe  to  be  the  truth  in  regard  to  this  matter : 

"1.  As  previously  asserted,  tonic  and  sedative  effects  of  a 
very  decided  character  can  be  obtained  from  franklinization 
by  either  insulation  or  sparks.  These  effects,  however,  are 
equal  neitfier  in  variety  nor  degree,  taking  the  cases  as  we  find 
them,  to  the  effects  of  dynamic  electricity  properly  and 
thoroughly  used  after  the  methods  of  general  faradization  and 
central  galvanization.  As  supplementing  these  methods, 
however,  when  in  protracted  cases  they  seem  in  a  measure  to 
have  lost  their  effects,  we  have  abundant  testimony  of  its 
value. 

"2.  It  has  long  been  known  that  many  temperaments  and 
conditions  of  disease  would  bear  faradization  or  galvanization 
readily,  and  yet  shrink  from  electrization  from  sparks,  while 
the  reverse  was  not  so  evident.  At  the  present  time  I  have 
under  my  care  two  women,  members  of  the  same  family,  both 
suffering  from  analogous  affections.  One  regards  general 
faradization  as  exceedingly  agreeable  and  is  benefited  by  it, 
but  shrinks  from  the  treatment  by  sparks,  and  even  dislikes 
the  milder  method  of  insulation,  and  subsequently  complains 
of  disagreeable  sensations  ;  the  other  much  prefers  the  more 
positive  treatment  by  franklinization. 

"3.  As  compared  with  the  faradic  current  alone,  franklinic 
electricity  has  undoubtedly  some  advantages  in  the  treat- 
ment of  some  forms  of  neuralgia  ;  but  as  compared  with  both 
the  galvanic  and  faradic  currents,  I  have  been  able  to  dem- 
onstrate no  such  advantage.  Galvanism  alone  is  superior  to 
franklinism  for  the  relief  of  pain,  and  yet  the  latter  occa- 
sionally aids  the  former  method  not  a  little,  on  the  same 
principle  that  it  may  be  often  used  to  supplement  the  use  of 
dynamic  electricity  for  the  production  of  tonic  and  sedative 
effects. 


120  MEDICAL  GYNECOLOGY. 

"4.  In  electro-diagnosis  franklinic  electricity  (excepting 
the  static  induction  current)  is  of  but  limited  value,  those 
qualitative  and  quantitative  changes  which  are  so  important 
as  indicating  structural  degeneration  being  satisfactorily 
made  evident  only  through  the  action  of  the  two  forms  of 
dynamic  electricity.  In  electro-surgery,  also,  franklinic  elec- 
tricity is  of  but  little  value." 

THS   INTERRUFTSD   HIGH-VOLTAGE   PRIMARY   OR  MIXED 

CURRENT. 

Dr.  George  J.  Engelmann,  of  St.  Louis,  in  the  Medical 
News,  February  3,  1894,  says : 

"The  interrupted  high-voltage  primary  or  mixed  current 
is  one  of  the  results  of  experiment  with  my  new  independent 
interrupter,  devised  for  my  faradic  apparatus,  but  to  be  used 
also  in  connection  with  any  galvanic  and  faradic  apparatus ; 
it  has  proved  to  possess  an  individuality  peculiar  to  itself  and 
of  great  physiologic  eflBciency,  so  that  I  am  convinced  of  its 
therapeutic  value,  and  present  it  for  the  consideration  of  the 
profession. 

"This  current,  which  I  term  the  interrupted  higJi-toltage 
primary  or  mixed  current,  is  obtained  by  the  interruption  of 
the  galvanic  flow  passing  through  the  secondary  coil  of  the 
faradic  apparatus,  and  is  taken  from  the  terminals  of  that 
secondary  coil,  here  used  as  a  primary,  which  is  of  higher 
voltage,  of  many  more  winds  and  greater  resistance  than  the 
ordinary  primary  in  medical  induction  instruments. 

"The  current  so  obtained  is  hence  not  precisely  identical 
with  the  primary  faradic,  and  may  properly  be  tenned  a 
mixed  current,  if  not  an  interrupted  primary  of  higher 
voltage. 

"A  well-regulated,  controllable  interrupter  is,  above  all, 
necessary.  Any  galvanic  battery  may  be  used  ;  one  pole  is 
connected  with  the  interrupter,  and  through  this  to  one  of 
the  terminals  of  the  secondary  coil  of  the  faradic  apparatus 
(the  binding  post  from  which  the  secondary  current  is  taken) ; 
the  other  pole  of  the  galvanic  battery  is  connected  directly 


ELECTRICITY   IN  THE   THERAPEUTICS  OP   GYNECOLOGY.     121 

with  the  remaining  terminal  of  the  secondary  coil,  and  with 
these  same  two  terminals  the  rheophores  carrying  the  elec- 
trodes are  connected. 

"  A  current  so  produced  combines  the  characteristics  of 
the  galvanic  and  the  induction  flow ;  it  has  the  same  galvano- 
metric  quantity  and  the  same  chemic  effect  as  a  simple  gal- 


FiG.  3. — B,  Galvanic  battery;  i,  interrupter;  sc,  secondary  coil;  —  x  and  +  x,  ter- 
minals of  coil ;  c,  core  and  primary  coil ;  e,  e,  electrodes. 


vanic  current  of  the  same  intensity,  or  from  the  same  number 
of  cells  applied  in  the  same  manner  plus  the  voltage  and  the 
physiologic  effects  obtained  from  the  winds  of  the  coil.  Coil 
and  patient  being  connected  in  multiple,  the  resistance  is  di- 
minished and  the  current  increased,  but  increased  in  voltao-e 
rather  than  amperage — converted,  I  may  say. 

'''Y\iQpliysiologic  effects  are  peculiar,  and  differ  material- 
ly from  those  of  any  other  form  of  electricity  in  medical  use, 
the  current  combining,  as  it  were,  the  quantity  and  chemic 
effect  of  the  galvanic  with  the  voltage  of  the  faradic  ;  the 
effects  resemble  most  nearly  those  of  t\%  primary  faradic,  but 
are  more  powerful  and  indicative  of  greater  quantity,  most 
marked  in  their  action  upon  muscular  fiber,  which  is  affected 
by  this  as  by  no  other  form  of  electricity. 

"A  variety  of  effects  are  produced  by  the  use  of  different 
current  intensities  and  different  coils  ;  yet  while  this  current 
will  undoubtedly  be  of  distinct  value  in  certain  nerve  lesions, 
it  will  prove  pre-eminently  a  muscle  current,  as  it  contracts 
the  muscle  most  perfectly,  acting  upon  every  fiber  in  the  most 
marked  manner,  like  a  powerful  interstitial  or  intercellular 
massage. 


122  MEDICAL  GYNECOLOGY. 

"The  character  and  effect  of  the  current  depend  upon  the 
following  elements,  which  must  be  noted,  as  it  is  by  a  varia- 
tion in  these  factors  that  the  varying  therapeutic  results  are 
obtained : 

"1.  The  number  of  cells  or  intensity  of  the  primary  bat- 
tery flow. 

"2.  The  resistance  and  number  of  winds  of  (the  secon- 
dary) coil. 

"  3.  The  number  of  interruptions. 

' '  4.  The  position  of  the  secondary  coil  in  reference  to  the 
core  and  primary. 

"5.  The  character  and  location  of  the  electrodes. 

"1.  The  number  of  cells  used  or  the  intensity  of  the  pri- 
mary battery  flow  determines  the  galvanometric  measure  and 
chemic  effect.  These  being  the  same  as  from  an  ordinary  gal- 
vanic current  without  insertion  of  the  coil  and  applied  in  the 
same  manner,  it  is  evident  that  the  character  of  the  current 
must  in  a  measure  depend  upon  this  factor ;  but  as  voltage 
and  induction  effects  are  prominent,  the  number  of  cells  to  be 
employed  is  determined,  not  by  the  chemic  effect  to  be  pro- 
duced, but  by  the  coil  to  be  used.  Only  one  cell  can  be  em- 
ployed in  connection  with  a  short  coil,  the  number  of  cells 
being  increased  with  the  resistance  and  number  of  winds  in 
the  coil ;  but  more  than  ten  or  twelve  cells,  if  in  good  condi- 
tion, can  hardly  be  used  to  good  advantage,  even  with  the 
long  fine  coils,  at  least  on  healthy  tissues. 

"2.  It  is  the  coil  pre-eminently  which  determines  the  char- 
acter and  effect  of  the  current,  the  resistance  and  number  of 
winds  materially  varying  its  physiologic  value,  but  not  in  pre- 
cisely the  same  manner  as  when  used  as  a  secondary  in  the 
faradic  current  proper.  The  faradic  current  from  a  coil  of 
high  voltage,  or  many  winds,  has  least  quantity,  while  the 
mixed  current  from  this  coil  is  of  necessity  one  of  greatest 
quantity. 

"  The  lower  the  resistance  of  the  coil  and  the  less  the  num- 
ber of  winds,  the  more  powerful  the  induction  effect  and  the 
less  the  quantity  of  the  primary  galvanic  force  to  be  em- 


ELECTRICITY   IN   THE   THERAPEUTICS   OP   GYNECOLOGY.     123 

ployed  :  No.  I  coil  (Engelmann),  0*8  ohms  R.,  528  winds,  has 
an  effect,  both  motor  and  sensory,  too  powerful  for  thera- 
peutic use,  even  with  one  single  cell  of  the  weakest  Le- 
clanche. 

"No.  II,  the  medium  coil,  13  ohms  E,.,  1,750  winds,  with 
one  cell  from  any  galvanic  battery,  produces  the  most  satis- 
factory, deep,  muscle-contracting  currents,  permeating  every 
fiber.  This  is  par  excellence  the  coil  which  gives  value  to 
the  current,  and  it  is  remarkable  how  completely  it  can  be 


\ 

usual 

curve. 

/ 

^ 

- 

hiqhi/o 

Itaae  p 

rimary./ 

0    5,000   10,000   15,000  20,000  25,000  30,000  35,000  40,000. 

Fig.  4. 

confined  to  a  distinct  muscle  by  the  location  of  the  electrodes ; 
while  permeating  its  fibers  it  does  not  seem  to  radiate  be- 
yond. 

"For  the  developing  of  the  most  satisfactory  results,  the 
number  of  cells  used  must  be  increased  with  the  resistance 
and  number  of  winds  in  the  coil : 


Feet. 

Wire. 

Winds. 

Number  of  cells 
found  to  be  effective. 

For  a  coil  of 

1,500 
3,000 
4,500 

36 
36 
36 

4,000 

7.000 

10,000 

4  to  5 

7 

U                    (( 

9  to  11 

"By  longer  coils  muscular  contractions  are  likewise  pro- 
duced ;  but  these  are  more  painful,  and  the  chemic  effects  of 
the  galvanic  current  begin  to  assume  prominence  ;  these 
should  prove  efficient  for  other  therapeutic  purposes  when 
more  marked  galvanic  effects  are  called  for. 

"  3.  Change  of  relation  between  the  secondary  coil  and  the 


124  MEDICAL  GYNECOLOGY. 

primary  coil  and  core — i.  e.,  the  moving  to  and  fro  of  the  coil 
on  the  scaled  slide — varies  the  intensity  of  physiologic  effect. 
This  variation  of  intensity  is  similar  to  that  of  the  primary 
faradic,  but  differs  in  some  features  ;  if  coils  of  low  electro- 
motor force  a,re  used,  the  intensity  of  physiologic  effect  is  in- 
creased by  a  sliding  out  of  the  coil  away  from  the  core  ;  this 
is  most  marked  in  the  coil  of  fewest  winds,  coil  I,  528  winds  ; 
somewhat  less  so,  but  still  very  decided,  in  coil  II,  1,760 
winds,  13  ohms  R.  ;  coils  of  higher  E.  M.  F.,  longer;  fine- 
wire  coils,  on  the  contrary,  weaken  the  current  effect  by  the 
drawing  out  of  the  coil,  or  the  moving  away  from  the  core ; 
this  is  true,  even  of  the  coil  of  1,500  feet,  or  4,000  winds,  and 
of  the  muscle  coil  of  fine  wire  in  multiple,  6,500  winds,  and 
only  4  ohms  R. 

"The  true  primary  coil  of  the  apparatus  is  ignored  in  these 
experiments,  and  its  terminals  are  not  connected.  When  this 
is  done  it  acts  as  a  damper,  like  the  copper  tube  of  Duchesne, 
to  weaken  the  current. 

"4.  The  number  of  interruptions,  or  the  rates  of  vibration, 
control  the  physiologic  effect  of  this  current,  as  they  do  that 
of  the  faradic,  while  the  chemic  and  galvanometric  action  is 
affected  but  little  and  that  in  a  contrary  sense. 

"  Interruption  and  alternation  affect  the  physiologic  action 
of  this  current  in  the  same  manner,  but  I  shall  speak  only  of 
interruption  pure  and  simple,  as  it  is  the  interrupted  primary 
which  will  prove  of  greatest  therapeutic  value,  this  being 
more  agreeable,  less  painful,  and  harsh  than  the  alternating, 
and  equally,  if  not  more,  efllcacious  as  a  muscle  contractor, 
so  that  the  alternating  primary  will  only  be  used  when  it  is 
of  importance  that  all  chemic  action  be  avoided.  Both  cur- 
rents, interrupted  and  alternating,  will  respond  to  certain 
therapeutic  indications  ;  but  as  a  simple  muscle  contractor  the 
more  irritating  and  disagreeable  alternating  will  find  little 
favor  as  compared  with  the  interrupted  current ;  both,  how- 
ever, respond  in  precisely  the  same  way,  as  regards  physio- 
logic effect,  to  variation  in  the  rate  of  interruption. 

"  Other  conditions  being  equal,  the  same  number  of  inter- 


ELECTRICITY  IN  THE   THERAPEUTICS  OP  GYNECOLOGY.     125 

riiptions  and  alternations  produce  the  same  effect — i.  e,,  10,000 
interruptions  have  the  same  comparative  effect  as  20,000 
alternations  upon  the  current.  As  in  the  secondary  faradic, 
the  effect  of  the  current  increases  with  the  rapidity  of  inter- 
ruption from  1  to  2,500  or  3,000  per  minute,  and,  after  attain- 
ing a  maximum  effect,  decreases  with  increased  rapidity  of 
interruption  until  a  rapidity  is  reached  with  which  all  sensa- 
tion ceases.  Though  the  galvanometric  effect  is  unchanged, 
the  chemic  effect  increases  ;  the  more  intense  the  current,  the 
greater  the  number  of  interruptions  necessary  to  completely 
annul  its  effect. 

"Coil  I,  heavy,  with  one  cell,  causes  powerful  and  painful 
contractions — too  violent  for  general  use  with  the  ordinary 
rate  of  interruption  ;  yet  it  ceases  to  have  any  effect,  or  to  be 
felt,  with  14,000  interruptions  per  minute  (this  when  full  in, 
over  core,  with  small  sponge  electrodes  to  upper  and  lower 
arm,  the  effect  depending  greatly  upon  the  moisture  of  the 
electrodes  and  the  pressure  uj)on  them). 

"The  10,000-wind  coil,  4,500  feet  of  36  wire,  11  cells, 
sponge  electrodes  to  upper  and  lower  arms,  ceases  to  be  felt 
at  25,000,  while  if  only  7  cells  are  used,  the  same  result  is 
accomplished  by  20,000  interruptions  per  minute. 

"The  general  law  mentioned — of  increase  of  effect  with 
increase  in  rapidity  of  interruption,  then  decrease  with  still 
greater  rapidity— holds  good  with  one  curious  exception,  true 
of  the  secondary  faradic,  as  it  is  of  the  interrupted  or  alter- 
nating high-voltage  primary  ;  and  this  interesting  phenome- 
non, which  merits  a  more  thorough  discussion  elsewhere,  I 
must  here  at  least  note  :  It  is  that  currents  from  certain  coils, 
as  far  as  I  have  observed,  from  5,000  to  10,000  winds,  36  wire, 
under  certain  conditions,  after  passing  that  rapidity  of  inter- 
ruption at  which  they  cease  to  be  felt,  reappear  with  greater 
rapidity,  again  attain  the  previous  maximum,  to  again  lose 
all  effect  with  still  greater  frequency  of  interruption.  In 
place  of  the  simple  rise  and  fall,  there  is  a  second  shorter 
and  additional  curve  of  rapid  rise  to  the  previous  maximum 
and  fall  to  zero. 


126  MEDICAL   GYNECOLOGY. 

"The  36 -wire  coil  of  10,000  winds,  with  11-cell  primary 
galvanic  force,  ceases  to  be  felt  with  25,000  interruptions, 
then  reappears,  regains  its  previous  efficiency  at  30,000,  and 
again  weakens  as  the  interruptions  grow"  more  rapid,  to  com- 
pletely fade  away  as  they  attain  a  speed  of  40,000  per  min- 
ute ;  if  fewer  cells  are  used  with  the  same  coii,  precisely  the 
same  phenomenon  is  observed,  the  same  effects  being  pro- 
duced by  lower  rates  of  interruption  as  the  current  is  weaker. 

"5.  That  the  character  of  the  electrode,  which  determines 
penetration  and  surface  resistance,  influences  this  current,  as 
it  does  both  galvanic  and  faradic,  need  hardly  be  mentioned  ; 
material,  size,  degree  of  moisture,  location,  and  pressure  upon 
the  electrode,  all  serve  to  vary  the  sensation  and  effect  of  the 
current,  and  must  be  considered  as  determining  factors.  ..." 


CHAPTER  XII. 

MUSCULAE  EXERCISE,    MASSAGE,    AND   DIET  I]vr   DISEASE. 

ft 

MUSCULAR    EXERCISE. 

In  the  management  of  the  diseases  of  the  pelvic  organs, 
especially  during  convalescence,  it  is  often  necessary  to  em- 
ploy muscular  exercises,  and,  in  order  to  be  effective,  the  ex- 
ercises should  be  taken  in  the  recumbent  position.  The  ex- 
tremities can  be  exercised  as  follows :  The  patient  resting 
upon  the  back,  one  leg  is  raised  so  as  to  form  an  obtuse  angle 
with  the  body,  held  in  position  for  a  minute  and  then  slowly 
returned  to  the  bed.  This  is  repeated  as  many  times  as  the 
patient  can  do  so  without  being  tired.  Then  the  leg  is  flexed 
and  extended  several  times,  then  the  leg  flexed  upon  the  thigh 
and  the  thigh  flexed  upon  the  body  ;  each  movement  is  made 
as  often  as  the  patient  can  do  so  without  muscular  fatigue. 
Then  the  other  leg  is  treated  in  the  same  way.  The  leg  is 
raised  straight  and  abducted  and  adducted  as  many  times  as 
the  patient  can  do  so  without  discomfort. 

The  arms  are  exercised  in  a  similar  way,  only  that  both 
arms  can  be  used  at  the  same  time.  First,  they  are  raised 
so  as  to  form  a  right  angle  to  the  body  ;  this  is  repeated  sev- 
eral times ;  then  they  are  extended  above  the  head  and  down 
again  straight  by  the  body.  Then  the  forearms  are  flexed 
upon  the  arms.  The  hands  are  exercised  by  forcibly  closing 
and  opening  the  fingers  and  bending  the  wrist  in  every  pos- 
sible position.  All  these  exercises  should  be  continued  until 
a  slight  feeling  of  fatigue  is  observed. 

I  was  first  led  to  adopt  this  method  of  exercising  at  the 
suggestion  of  a  patient  who  was  a  noted  gymnast.     She  re- 

127 


128 


MEDICAL   GYNECOLOGY. 


Fig.  5. 


quired  a  surgical  operation,  and  during  convalescence  she 
devised  this  system  of  exercise  and  practiced  it  with  benefit. 
I  adopted  it  and  have  used  it  in  practice  ever  since,  and  have 

found  it  beneficial  in 
cases  with  active  pel- 
vic disease  to  ele- 
vate the  foot  of  the 
bed  during  exercise. 
This  treatment  is  es- 
pecially adapted  to 
cases  that  have  prof- 
ited sufiiciently  by  massage  to  be  able  to  take  active  exercise. 
There  is,  of  course,  nothing  original  in  this  ;  it  is  merely  an 
adaptation  of  ordinary  light  gymnastics  to  the  treatment  of 
the  sick  who  are  confined  to  bed  and  to  those  suffering  from 
affections  of  the  ]Delvic  organs  who  can  not  exercise  in  the 
erect  position. 

When  patients  have  progressed  toward  recovery  there  are 
other  exercises  that  may  be  employed  to  strengthen  the  mus- 
cles of  the  back,  abdomen,  trunk,  and  limbs,  when  these  have 
become  weakened  by  prolonged  inactivity  or  sickness. 

Dr.  Savage  (quoted  in  Dr.  R.  L.  Dickenson's  article.  Simple 
and  Practical  Methods  in  Dress  Reform)  advises  (for  strength- 
ening the  abdominal 
muscles)  ''  the  patient 
to  lie  on  her  back  in 
bed,  to  raise  the  head 
and  shoulders  a  few 
inches  from  the  pil- 
low, and,  holding  the 
head  steadily  in  that  position  for  a  moment,  to  slowly  drop 
back  again  to  the  pillow  (Fig.  5).  This  is  repeated  imme- 
diately, there  is  an  interval  of  rest,  then  twice  again  is  the 
motion  gone  through — fatigue  never  being  induced — and  five 
repetitions  finish  this  exercise. 

"  Still  later  the  feet  are  to  be  fixed  against  the  foot- 
board, and   the  patient  assumes  a  sitting  position,  at  first 


Fig.  6. 


MUSCULAR  EXERCISE. 


129 


using  the  pillow  ;  but,  soon  giving  this  up,  the  woman  is  to 
rest  flat  on  her  back  and  go  through  this  exercise  five  times. 

"Again,  the  patient,  lying  on  her  back,  brings  the  bended 
knee  toward  the  face  as  far  as  is  possible  without  effort ; 
then  it  is  forced  toward 
the  face  an  inch  or  two 
(Fig.  6).  This  is  done 
with  the  other  leg.  The 
exercise  is  five  times 
with  each  knee. 

' '  A  more  difficult  ex- 
ercise is — the  woman  on 
her  back — to  slowly  raise 


-i4X'-. 


,^iS?!#~^ 


first  one  leg  and   then 


Fig.  7. 


the  other  from  the  hori- 
zontal to  the  vertical  position  (Fig.  7).     This  is  done  ten  times 
with  each  leg. 

"Finally  the  abdominal  muscles  are  strengthened  by  plac- 
ing on  the  abdomen  any  flat  weight — the  woman  on  her  back 
— and  then  deep  abdominal  breaths  are  taken  to  lift  the 
weight  as  high  as  possible,  holding  it  there  a  few  seconds. 
A  slow  expiratory  effort  follows. 

"This  strengthens  the  muscles  of  the  Tjacli.  The  woman — 
lying  on  her  back  with  her  feet  drawn  up — raises  her  hips 
until  the  thigh  is  on  a  line  with  the  body,  keeps  this  position 
a  moment,  and  then  slowly 
drops  back  (Fig.  8).  This  is 
repeated  five  or  ten  times. 

"Lying full  length, prone, 
with  her  arms  at  her  side, 
the  woman  breathes  deeply, 
raises  head  and  shoulders 
from  the  pillow,  keeps  this  position  a  moment,  and  then 
slowly  lets  the  head  and  shoulders  fall  back  (Fig.  9). 

"The  following  is  more  difficult:  The  body  is  lifted  off 
the  bed  four  or  five  times,  with  a  rest  between  each  effort, 
the  elbows  and  toes  being  the  only  points  of  support  (Fig.  10). 


Fig.  8. 


130 


MEDICAL   GYNECOLOGY. 


Fig.  9. 


"Finally  the  lateral  muscles  of  the  trunk  can  be  strength- 
ened— the  woman  lying  on  one  side — by  lifting  the  hips  and 
making  the  shoulder  and  lower  leg  the  points  of  support." 

Systematic  exercise  is  irksome,  and  when  solitary  still 
more  so.  Few  can  or  will  follow  these  directions,  and  the 
gymnasium  or  out-of-door  sports,  with  their  variety,  compan- 
ionship, stimulation,  and  emulation,  will  be  the  surest — per- 
haps best — means  of  com- 
pletely restoring  muscu- 
lar strength.  But  the 
exercises  given  above  are 
adapted  to  those  who  are 
not  well  enough  to  take 
out-of-door  work. 
Each  exercise  or  movement  should  be  repeated  until  the 
muscles  are  beginning  to  feel  fatigued,  a  note  made  of  the 
number  of  repetitions,  and  one  or  two  added  each  day.  When 
progress  is  evident,  walking  should  be  begun,  at  first  with  the 
support  of  the  attendant  and  then  without ;  but,  like  all  other 
efforts,  it  should  be  regulated  and  increased  by  degrees. 
Next  come  riding  and  walking,  and  finally  diversion  may  be 
followed  by  useful  occupation. 

All  through  the  treatment  baths  should  be  used  to  keep 
the  skin  active  and  clean,  and  also  as  an  occupation  and  ex- 
ercise. The  form  of  bath  should  be  adapted  to  each  case. 
That  to  which  a  patient  is  accustomed  and  which  is  agree- 
able to  her,  and  not 
followed  by  any  ill 
effect,  should  be  em- 
ployed. 

There  are  other 
exercises,  used  in 
special  affections 
(given  by  Dickenson  in  Hare's  System  of  Practical  Thera- 
peutics), which  are  worthy  of  attention.  The  following  is 
quoted,  with  some  slight  verbal  changes,  from  the  article 
on  Weak  Levator  Ani  and  Relaxed  Pelvic  Floor:   "1.  The 


Fig.  10. 


MUSCULAR   EXERCISE.  131 

patient  is  taught  to  contract  the  levator  and  draw  up  the  pel- 
vic floor,  drawing  back  the  abdominal  wall  by  deep  breath- 
ing at  the  same  time,  standing 
against  a  wall  or  sitting.  2. 
Lying  on  the  back,  feet  drawn 
up  and  crossed ;  buttocks  are 
raised  ;  then  the  knees  are 
slowly  opened  wide  against 
her  own  resistance   (Fig.   11). 

3.  Knee-chest  position.  Patient  takes  deep  abdominal  breath, 
then  expresses  it  by  contracting  the  belly  muscles  forcibly, 
at  the  same  time  drawing  up  as  strongly  as  possible  the  mus- 
cles of  the  pelvic  floor  (Fig.  11)." 

"MUSCULAR  EXERCISES   FOR  AMENORRHCEA." 

I  give  these  without  the  illustrations. 

"First,  with  one  foot  forward  a  deep  breath  is  drawn  and 
the  arms  elevated  above  the  head,  parallel  in  front  and  palms 
facing  inward  ;  then,  during  expiration,  they  are  brought 
down  laterally  with  palms  facing  forward. 

"Secondly,  lying  on  the  back,  the  lower  extremities  un- 
supported and  the  legs  crossed,  the  toes  execute  circles  from 
within  outward,  the  movement  occurring  in  the  ankle  Joint. 
This  is  repeated  reversely  eight  or  ten  times  in  each  posi- 
tion. 

"A  third  exercise  is  for  the  patient  to  stand  upright,  with 
feet  well  apart,  the  buttocks  resting  against  a  table,  and  arms 
above  the  head.  The  trunk  is  flexed  on  the  pelvis  sidewise 
and  forward,  slowly,  five  times  to  each  side,  pausing  between 
each  motion. 

"A  fourth  is  with  the  hands  on  the  back  of  a  chair,  one 
foot  upon  another  chair  behind  her ;  the  patient  rises  on  the 
toes  of  the  other  foot,  then  drops  toward  the  ground  by  bend- 
ing the  knees,  then  resumes  the  extended  position  on  the 
toes,  finally  dropping  on  her  heel  as  before  the  start.  This  is 
done  slowly  five  times  with  each  foot. 

"Again,  the  patient  stands  upright,  with  feet  apart  and 


132  MEDICAL  GYNIECOLOGY. 

arms  elevated  ;  the  body  is  bent  forward,  then  backward,  then 
pauses  in  an  upright  position.     Five  times  each. 

"  Sixth,  resting  a  hand  on  the  back  of  a  chair  before  her 
and  standing  on  the  leg  of  the  same  side  ;  the  other  leg 
is  raised,  and  the  knee  rotates  from  within  out.  Reverse 
the  legs. 

"Seventh,  with  hands  on  the  hips  and  body  well  back,  a 
running  motion  is  executed ;  but  the  patient  remains  in  the 
same  spot,  each  step  bringing  the  thigh  up  on  a  level,  hori- 
zontal plane.  Ten  times  rapidly,  then  three  or  four  times 
with  an  interval  between  each.  This  sends  a  good  current  of 
blood  to  the  pelvis. 

"Eighth,  standing  with  feet  apart  and  hands  on  the  hips, 
the  head  describes  a  circle.     Five  times  in  each  direction. 

"Ninth,  kneeling  on  a  cushion  with  knees  apart,  the  body 
is  bent  backward  and  returns  slowly  to  the  perpendicular, 
five  to  seven  times. 

"The  tenth  is  a  passive  motion.  The  patient  is  semi- 
recumbent.  The  assistant  lifts  one  leg  by  a  hand  in  the  pop- 
liteal space  and  another  on  the  sole.  The  thigh  is  flexed  on 
the  abdomen,  carrying  the  knee  outward,  describing  a  small 
circle,  repeating  the  motion  ten  times,  while  increasing  the 
rapidity  of  it ;  after  a  pause  the  assistant  again  commences, 
and  thirty  or  forty  movements  are  given  to  each  leg,  the 
patient  being  absolutely  relaxed.  Flexion  and  extension  can 
be  made  against  resistance. 

"Metrorrhagia  is  treated  by  movements  that  are  quite  as 
elaborate.  First,  the  patient  sits  facing  the  giver  of  the 
exercises,  with  her  hands  on  her  hips  and  her  knees  apart. 
The  operator  puts  one  hand  on  her  shoulder  and  the  other 
under  the  opposite  axilla,  drawing  her  forward  and  simulta- 
neously twisting  her  body  on  the  pelvis.  She  is  to  resist  the 
forward  motion  and  the  operator  is  to  resist  the  backward 
motion,  six  times  for  each  side.  Then  a  direct  forward-and- 
back  pull  is  made,  the  patient  keeping  the  back  muscles  very 
tense. 

"Secondly,  the  patient  is  to  kneel  with  her  hands  on  her 


MUSCULAR  EXERCISE.  133 

hips.  The  operator,  behind  her,  puts  his  knee  against  her  and 
his  hands  under  her  axillae  ;  she  bends  forward  while  he 
resists,  and  then  he  draws  her  upright  while  she  resists. 
When  she  is  bent  forward  he  rapidly  twists  her  body  several 
times  above  the  pelvis.  This  is  done  five  times,  a  rest  be- 
tween each  manoeuvre. 

"Thirdly,  the  patient  stands  in  a  doorway,  the  arms  verti- 
cal, hands  against  the  top  of  the  doorway,  while  the  operator 
places  one  hand  on  the  abdomen  and  the  other  between  the 
scapulae  and  pushes  her  forward.  As  she  regains  her  first 
position  he  resists  and  pushes  her  hand  upward  ten  times. 

"Fourthly,  the  patient  stands  with  her  back  against  the 
wall,  her  hands  on  her  hips,  and  she  places  an  ankle  in  the 
operator's  hand,  while  he  steadies  her  by  placing  his  other 
hand  against  the  iliac  crest  of  the  same  side.  He  draws  that 
leg  up  and  out,  she  resisting,  and  he  then  resists  while  she 
lowers  the  leg.  This  pump-handle  motion  is  repeated  five 
times  for  each  side. 

"Fifthly,  the  patient  leans  against  a  chair  or  bedpost  at 
as  great  a  slant  with  the  floor  as  possible,  while  the  operator, 
one  hand  under  the  abdomen,  lifts  the  foot,  the  patient  pas- 
sive. Then  he  depresses  the  leg  while  she  resists.  Five  times 
for  each  side. 

"Sixthly,  the  patient,  leaning  forward,  puts  her  hands 
against  the  wall,  chest  level,  turns  the  elbows  out,  and  keeps 
the  feet  apart.  The  operator,  one  hand  supporting  the  ab- 
domen, taps  lightly  on  the  sacral  lumbar  vertebrae  with  half- 
closed  hand. 

"Seventhly,  the  patient,  supine,  draws  her  feet  together 
under  the  bended  knees,  lifting  the  hips  clear  of  the  couch, 
the  operator  resisting  an  attempt  to  draw  the  knees  together. 
Five  times.  Then  he  resists  an  attempt  to  separate  the  knees. 
This  manoeuvre  strengthens  the  levator. 

"  Lastly,  if  the  patient  is  physically  incapable  of  perform- 
ing any  of  these  movements,  she  reaches  her  hands  to  the 
operator,  the  elbows  slightly  bent,  while  he  moves  her  arms 
at  the  shoulder  joints  in  all  sorts  of  circling  motions  while 


134  MEDICAL   GYNECOLOGY. 

she  is  passive.  She  then  bends  the  arms,  he  resisting  flex- 
ion, she  extension." 

Brandt  has  also,  with  brilliant  results,  instituted  a  system 
of  gymnastics  and  massage  of  the  pelvic  organs.  With  one 
hand  on  the  hypogastrium,  he  "kneads"  the  pelvic  organs 
and  tissues  that  are  lifted  within  reach  by  a  stationary  finger 
in  the  vagina.  Exudations  and  adhesions  are  made  to  disap- 
pear, and  fixed  ovaries  and  retroverted  uteri  are  restored  to 
normal  positions.  The  method  is  applicable  in  chronic  in- 
flammation of  the  tissues  of  the  pelvis,  with  or  without  uter- 
ine displacement ;  in  displacement  and  fixation  of  the  ovaries, 
and  chronic  ovaritis  ;  in  relaxation  of  muscular  tissues  and 
all  that  results  therefrom  ;  and  perhaps  in  hsematocele. 

But  these  procedures  are  all  contraindicated  in  acute  in- 
flammations, gonorrhceal  infections,  extreme  sexual  nervous 
irritability,  and  where  the  abdominal  walls  are  very  thick 
and  fat. 

Now,  whether  by  masseur  or  masseuse,  no  one  of  these  or 
other  like  manoeuvres  should  be  performed  save  in  the  pres- 
ence of  a  third  person,  preferably  a  nurse  or  relation  of  the 
patient,  for  reasons  that  are  all  too  obvious.  It  is  understood 
that  the  Brandt  metJiod  is  expensive,  slow  in  effecting  a  cure, 
not  at  all  easy  to  learn,  and  dangerous  when  a  correct  diag- 
nosis has  not  been  made. 

SWEDISH  MOVEMENTS. 

"Swedish  movements  "is  a  branch  of  mechanical  thera- 
peutics whose  systematization,  as  is  well  known,  was  made 
by  Ling  in  the  early  part  of  the  present  century.  A  great 
many  machines  were  constructed,  by  means  of  which  differ- 
ent groups  of  muscles  were  moved  in  hundreds  of  ways. 
When  patients  could  not  or  would  not  exercise  their  mus- 
cles, these  machines  did  it  for  them.  As  much  fatigue  fol- 
lows this  artificial  exercise  as  the  natural. 

In  diseases  of  women  and  for  benefiting  those  who  are  not 
diseased,  but  feeble,  debilitated,  or  nervously  exhausted,  the 
only  claim  that  can  be  made  for  this  system  is  that  by  devel- 


MASSAGE.  135 

oping  the  muscular  tissue  to  its  full  capacity  undue  nervous 
irritability  is  diminished,  and  by  acting  on  groups  of  muscles 
a  derivative  action  is  obtained  and  engorged  and  congested 
organs  are  thereby  relieved.  This  form  of  exercise  seems 
to  me  most  applicable  for  chronic  functional  disorders.  Its 
complicated  apparatus  renders  it  impossible  for  the  use  of 
the  general  practitioner,  and  only  in  gymnasiums,  sanita- 
riums, and  institutions  especially  devoted  to  these  kinds  of 
remedial  agents  are  the  means  for  applying  it  found. 

MASSAGE. 

When  the  tissues  of  the  body  have  motion  communicated 
to  them  from  an  external  source  for  remedial  purposes,  the 
procedure  is  ' '  massage. " 

Massage  is  not,  properly  speaking,  for  physical  culture, 
but  is  of  therapeutic  value  only  ;  and  it  may  be  immediate 
(the  motion  being  communicated  directly  to  the  part  operated 
upon)  or  mediate,  w^hen  some  mechanism  produces  the  motion. 

Stroking,  kneading,  friction,  and  percussion  are  the  four 
chief  procedures. 

Stroldng  should  be  performed  by  the  palm  of  the  hand, 
and  its  motion  should  be  centripetal,  toward  the  heart.  At 
times  one  hand  is  placed  on  top  of  the  other  in  this  motion. 

Friction^  as  a  rule,  is  performed  by  the  tips  of  the  fingers 
over  small  areas,  but  the  thumb  is  far  better  than  the  fingers 
for  this.  A  good  masseur  does  not  irritate  the  skin  in  this 
process. 

Kneading  is  the  grasping  of  a  muscle  or  group  of  mus- 
cles by  one  or  both  hands  and  rolling  or  squeezing  it,  or 
them,  upon  the  part  subjacent.  When  a  limb  is  held  be- 
tv^een  the  palms  and  a  rapid  to-and-fro  movement  is  made, 
the  limb  being  rolled  back  and  forth  between  the  hands,  the 
motion  is  called  fulling,  because  fullers  or  bleachers  rub 
linen  thus.  And,  again,  when  the  alternate  successive  pres- 
sures and  relaxations  are  made  with  great  rapidity — and  this 
requires  a  masseur  of  skill  and  long  practice — kneading  is 
called  vibration. 


j^36  MEDICAL   GYNECOLOGY. 

Midway  between  kneading  and  percussion  is  'pressure 
with  the  finger  tips  or  knuckles. 

Percussion  is  the  last  distinct  method  in  massage.  The 
hand  may  be  used,  or  an  instrument  called  a  percussor  or 
muscle-heater.  The  best  ordinary  percussor  is  Klemm's,  and 
the  best  electric  percussor  is  that  of  Granville,  of  London. 
In  percussing,  the  masseur  may  perfonn  clapping,  chopping, 
whipping,  or  flagellation. 

In  this  work  I  do  not  think  it  necessary,  nor  indeed  at 
all  pertinent,  to  more  than  refer  briefly  to  massage  in  its  rela- 
tionships to  the  medical  diseases  of  women,  or  to  the  special 
regions  immediately  about  the  pelvic  organs. 

Abdominal  massage  is  only  efficacious  when  the  patient's 
abdominal  muscles  are  relaxed.  Should  fffical  accumula- 
tions be  suspected,  massage  about  the  caecum  and  sigmoid 
flexure  is  advised  chiefly  by  stroking.  General  massage  of 
the  abdomen  invariably  increases  peritoneal  absorption,  says 
Reibmayr  ;  and  the  absorption  of  free  fluid  from  the  abdom- 
inal cavity  is  accelerated.  This  scientist's  experiments  upon 
healthy  rabbits  are  most  interesting. 

There  is  no  doubt  but  that  rapid  circular  strokes  over  the 
abdomen  produce  a  marked  effect  upon  the  peristaltic  action 
of  the  intestines. 

Regarding  the  thermal  effects  of  abdominal  massage,  it  is 
found  that  it — without  movements — diminishes  the  tempera- 
ture of  the  extremities. 

Functional  derangements  of  the  liver  and  spleen,  v^hether 
with  or  without  congestion  and  engorgement,  are  quite 
amenable  to  massage. 

Digital  manipulation  of  the  gall  bladder  is  very  important, 
for  in  the  case  of  one  patient  who  had  passed  one  gallstone, 
as  many  as  seventy  were  subsequently  found  in  the  stools 
after  careful  massage  of  the  gall-bladder  region  ;  and  Yo- 
padze  praises  massage  in  catarrh  of  the  bile  duct. 

It  is  in  dyspepsia  and  in  functional  disorders  of  the  di- 
gestive apparatus  in  women  that  massage  of  the  abdomen  is 
of  great  benefit.     Food  is  not  retained  in  the  stomach  for  so 


MASSAGE.  137 

long  a  time,  and  the  gastric  and  biliary  secretions  are  stimu- 
lated. Of  course,  it  is  contraindicated  in  hypermobility  of 
the  stomach. 

Kneading  the  abdomen  for  that  most  prominent  of  all 
female  conditions — constipation — is  a  powerful  therapeutic 
agent ;  and  in  obstinate  cases  vibratory  movements  are  to  be 
resorted  to.  Reibmayr  says  it  is  the  surest  remedy  for  ha- 
bitual constipation. 

In  the  dyspepsia  of  chlorotic  girls  it  is  most  useful  ;  but 
should  gastric  ulcer  be  suspected  in  such  cases,  it  is  net)er  to 
be  employed. 

For  obesity  or  corpulency  in  women  and  for  excrementi- 
tious  plethora  abdominal  massage,  liver  clapping,  percussion 
of  the  spine,  and  strong  thigh  motions  to  aid  contraction  of 
the  abdominal  muscles — these,  with  the  correct  diet,  in  some 
cases  diminish  the  uncomfortable  and  sometimes  unsightly 
condition. 

Percussion  and  strong  stroking  are  the  best  means  for  the 
relief  of  ascites  by  massage. 

In  pelvic  engorgements  and  in  all  functional  uterine  de- 
rangements massage  and  movements  aid  other  methods  of 
treatment. 

In  prolapse  of  the  uterus  Brandt  advises  massage  and  cer- 
tain gymnastic  movements  strengthening  the  supports  of  the 
uterus  after  its  reposition.  The  method  is  most  successful 
when  the  tissues  are  young  and  have  not  lost  their  tone,  and 
after  their  restoration  by  surgery  where  tonic  reaction  is 
demanded. 

Brandt's  method  should  never  be  employed  in  acute  in- 
flammations or  upon  the  old  and  debilitated. 

The  preliminary  treatment  is  made  when  the  patient, 
standing,  bends  forward,  resting  her  hands  against  the  edge 
of  a  table,  when  the  physician  begins  a  slight  tapotement 
upon  the  sacrum  with  his  fist,  the  result  being  contraction  of 
the  vessels  when  the  seance  is  short,  and  dilatation  of  them 
when  it  is  prolonged. 

Following  this,  the  uterus  is  elevated  and  replaced  in  its 


138  MEDICAL  GYNECOLOGY. 

normal  anteverted  position  by  the  physician's  left  hand,  his 
right  hand  pushing  the  abdominal  wall  down  behind  the 
symphysis  but  in  front  of  the  strongly  anteverted  fundus. 
The  assistant  (and  an  assistant  is  always  required)  elevates 
the  uterus  standing  at  the  foot  of  the  bed,  bending  the 
patient's  hip  joints  at  an  angle  of  ninety  degrees  by  slipping 
a  hand  under  each  knee.  The  bent  extremities  of  the  patient 
press  against  his  pelvic  region,  but  her  knees  are  kept  well 
apart  and  her  feet  together. 

The  next  procedure  is  for  the  assistant,  with  arms  straight 
and  finger  tips  of  each  hand  close  together,  to  bend  forward 
over  the  patient  and  grasp  the  sides  of  the  uterus  not  too  low 
down  and  steadily  and  slowly  draw  it  up  along  the  curve  of 
the  pelvis  past  the  promontory.  After  having  been  raised  to 
this  position,  it  is  allowed  to  slip  from  the  assistant's  hands 
and  very  gently  slide  back  into  the  cavity. 

The  physician  maintains  it  in  anteflexion  as  it  sinks  and 
the  tissues  contract  to  hold  it ;  indeed,  vaginal  contraction 
around  the  tip  of  the  finger  is  often  felt.  This  procedure  is 
repeated  very  gently  two  or  three  times  during  each  visit. 

In  the  intervals  between  the  operations  the  physician's 
index  finger  sweeps  by  circular  motions  from  the  fundus 
toward  the  internal  orifice,  that  contractions  may  empty 
dilated  veins  and  thus  reduce  congestion.  It  is  claimed  that 
measurement  proves  diminution  in  size  of  the  uterus  after 
such  procedures.  I  must  say  that  the  value  of  Brandt's 
method  is  not  in  replacing  the  uterus  but  in  the  effect  upon 
the  nutrition  of  the  tissues  in  stimulating  the  circulation  and 
the  absorbents. 

Brandt  advises  massage  of  the  utero-sacral  ligaments,  for- 
bids the  use  of  grease  of  any  sort,  and  that  the  work  be  done 
outside  of  a  chemise  or  cloth,  so  that  the  hands  may  not  slip. 
IS'o  pain  should  be  induced  in  carrying  out  any  part  of  this 
programme. 

The  muscles  of  the  pelvic  floor,  the  levator  ani,  the  thigh 
abductors  and  adductors  are  strengthened  subsequently  by  the 
exercises  already  described  and  commended  for  that  purpose. 


MASSAGE.  139 

During  the  day  the  patient  should  often  lie  down  and, 
crossing  her  feet,  alternately  contract  and  relax  the  levator  ani. 

After  knee  resistance  the  patient  gently  turns,  to  assume 
the  knee-elbow  position,  and  thus  breathes  with  the  thorax 
alone,  pelvic  pressure  becoming  so  low  that  the  anteflexed 
uterus  will  remain  in  position.  Sacral  tapotement  is  gently 
made  while  the  patient  is  taking  rest  in  this  position. 

Excitation  and  stimulation  of  all  the  pelvic  tissues  result. 
Contractility  follows,  and  after  from  four  to  eight  weeks' 
treatment,  says  Brandt,  success  is  obtained  in  from  seventy  to 
eighty  per  cent  of  cases  ;  but  if,  after  two  weeks,  the  uterus 
does  not  remain  in  place,  the  author  of  this  method  gives  up 
all  hope  of  cure. 

Much  has  been  claimed  by  Brandt  and  his  followers  for 
massage  in  relieving  fixation  of  the  pelvic  organs  caused  by 
the  products  of  a  bygone  inflammation  ;  but  this  is  not  to  be 
undertaken  until  all  the  acute  symptoms  have  passed  and  the 
physician  is  fully  assured  that  there  are  no  pus  cavities  any- 
where within  the  pelvis.  Hence  the  treatment  is  limited  to 
inflammatory  exudations  and  adhesions,  when  the  treatment 
is  said  to  stimulate  the  absorbents  that  their  work  may  be 
performed  with  more  facility  and  speed.  All  the  salutary 
effects  upon  the  circulation  already  referred  to  are,  of  course, 
simultaneously  obtained. 

Peripheral  nerves  are  especially  amenable  to  treatment 
by  massage  ;  hence  neuralgise,  especially  hemicrania  or  mi- 
graine, are  frequently  relieved  by  such  treatment. 

Neurasthenia  with  its  attendant  train  of  symptoms  de- 
serves a  thorough  trial  of  all  forms  of  massage  in  any  plan  of 
treatment ;  and  even  those  who  deny  the  existence  of  this 
disease,  or  who  think  this  is  a  loose  term,  only  covering  a 
complex  of  symptoms,  nevertheless  lay  down  special  rules  for 
forms  of  massage  to  diminish  or  eradicate  such  symptoms. 

Finally,  in  the  line  of  general  rules,  twenty-four  hours 
may  usually  intervene  between  each  seance  of  thirty  or  forty 
minutes  duration. 

If  massage  is  not  given  directly  upon  the  naked  skin,  the 

10 


140  MEDICAL  GYNECOLOaY. 

lightest  clothing  should  intervene.  Concerning  lubrication 
of  the  skin  the  various  authorities  seem  to  be  at  odds  ;  and 
when  it  comes  to  the  question  what  force  shall  be  used,  much 
must  be  left  to  the  sagacity  of  the  manipulator  and  to  the  ap- 
preciation by  the  physician  of  age,  nutrition,  disease,  temper- 
ament, and  sensitiveness  of  the  patient. 

All  these  agents  just  considered  require  to  be  combined  at 
times  in  the  management  of  certain  cases ;  this  is  not  at  all 
an  easy  thing  to  do  in  private  practice,  and  it  seems,  therefore, 
expedient  that  a  few  words  should  be  said  regarding  institu- 
tions where  systematic  treatment  can  be  fully  carried  out. 
For  this  subject  the  reader  is  referred  to  page  155. 

DIET  IN  DISEASE   AND  THERAPEUTICS. 

There  are  certain  articles  of  diet  that  are  necessary  and 
allowable  in  all  cases  in  health  and  disease — water,  for  ex- 
ample. 

Water  should  be  pure.  This  all  understand,  and  all 
should  be  as  careful  to  have  pure  water  as  food,  since  the 
latter  is  cooked,  whereby  the  deleterious  matter — should  any 
have  existed — is  wholly  destroyed.  This  is  not  the  place  to 
describe  how  to  discover  im]Durities  in  water  or  the  number  of 
noxious  elements  that  may  be  found  therein.  It  is  enough  to 
say  that  water  given  to  the  sick  should  be  boiled  and  filtered, 
unless  it  is  known  to  be  pure,  and  that  this  procedure  should 
never  be  omitted. 

Distilled  water  charged  with  carbonic-acid  gas  is  even 
more  agreeable  than  this. 

Drinking-water  for  the  sick  may  be  medicated ;  we  can 
acidulate  it  with  cream  of  tartar,  lemon  juice,  or  any  of  the 
mineral  acids  indicated  in  a  given  case.  Alkalies  and  alka- 
line salts  may  also  be  added  in  sufficient  quantities  to  meet 
the  demands  of  certain  cases,  and,  in  order  to  make  the  drink 
agreeable,  charge  it  with  carbonic-acid  gas.  I  much  prefer 
to  prepare  the  water  that  my  patients  drink,  and  not  to  de- 
pend upon  the  mineral  waters  in  the  market,  which  may  be 
all  that  is  claimed  for  ordinary  use,  yet,  not  bearing   the 


DIET  IN  DISEASE.  141 

guarantee  of  a  reliable  pharmacist,  such  waters  may  not  be 
always  reliable  for  the  sick. 

The  great  majority  of  people  are  so  accustomed  to  drink 
regularly  either  tea,  coffee,  or  both,  that  most  sick  people 
can  take  them  almost  as  they  can  water.  Hence  they  demand 
a  word. 

First,  let  me  say  that  they  are  contraindicated  in  cases 
where  there  is  hypersesthesia,  insomnia,  and  irritability,  or 
at  least  they  are  then  to  be  taken  only  in  very  small  quan- 
tities. 

In  cases  of  exhaustion  they  are  often  the  most  reliable 
of  mild  stimulants  ;  and  while  they  may  not  be  restoratives, 
in  the  therapeutic  sense,  they  retard  waste,  preventing  ex- 
cessive destructive  metamorphosis. 

The  difference  in  effect  of  tea  and  coffee  is  not  so  readily 
made  out.  Some  believe  that  tea  is  more  of  a  nerve  sustainer, 
while  coffee  is  more  nutritious.  That  tea  favors  digestion,  or 
at  least  is  less  likely  to .  hamper  it  compared  with  coffee, 
seems  to  be  the  view  of  the  majority. 

There  are  no  rules  based  on  clinical  experience  for  guid- 
ance. Tea  agrees  with  some,  coffee  with  others,  and  still 
others  can  not  suffer  either.  Only  the  patient's  past  experi- 
ence or  a  carefully  conducted  trial  will  suffice  to  determine. 

In  cases  of  shock  after  abdominal  operations  I  have  often 
found  tea  more  invigorating  and  also  more  acceptable  than 
any  form  of  alcohol  or  meat  extract.  Again,  while  many 
agents  and  drugs  depress  bodily  temperature,  the  active  prin- 
ciple of  tea  is  one  of  the  very  few  that  elevates  it,  and  this 
is  followed  by  no  such  fall  as  that  ensuing  after  ingestion  of 
alcoholic  stimulants. 

Alcohol  in  gynecology  is  seldom  called  for  save  after  very 
serious  operations,  or  in  those  who  have  been  accustomed  to 
it ;  and  even  then  it  is  injurious  if  too  long  continued. 

IN'o  form  of  alcohol  can  be  expected  to  suit  every  case,  or 
class  of  cases.  Beer  is  the  chosen  and  acceptable  beverage 
for  one,  champagne  for  another,  and  for  still  another  the  dis- 
tilled liquors  with  the  charged  waters. 


142  MEDICAL  GYNECOLOGY. 

Fluid  Diet  in  Acute  Cases. — In  diseases  running  a  short  conrse 
it  is  only  the  kind  and  purity  of  food  that  need  claim  the 
physician's  attention,  not  the  quantity.  The  stomach  is  the 
part  of  the  digestive  system  that  in  acute  cases  first  becomes 
inefficient ;  solids  and  meats  can  not,  therefore,  be  given. 
Milk,  gruels,  eggs  in  some  fluid,  and  all  the  beef  extracts  are 
the  foods  usually  given. 

Milk  is  the  best  food  in  diseases  accompanied  with  fever, 
despite  its  coagulation  oftentimes  in  the  intestinal  canal, 
and  notwithstanding  it  is  indigestible  for  some  people. 

Milk  must  in  all  cases  be  boiled  and  then  diluted,  prefer- 
ably with  Yichy,  Apollinaris,  or  distilled  water  charged  with 
carbonic-acid  gas.  It  is  administered  in  small  quantities,  but 
at  frequent  intervals — two  ounces  of  milk  in  two  ounces  of 
some  water. 

Whey  is  milk  from  which  the  caseine  and  much  of  the  fat 
have  been  separated  by  coagulation  and  straining.  It  can  be 
given  when  milk  is  disagreeable,  and  can  be  made  more  nu- 
tritious by  the  addition  of  beef  juice  or  the  beaten  yolk  of  an 
Qgg.  I  use  whey  a  great  deal,  and  find  it  the  most  nourishing 
and  easily  appropriated  food  at  my  command. 

Eggs  are  a  complete  food,  containing,  as  milk  does,  all 
the  elements  necessary  for  the  nutrition  of  the  body.  Beaten 
np  with  hot  water  and  strained,  they  can  be  added  to  a  clear 
soup  or  broth.  An  English  method  is  to  beat  up  an  %g^  in 
a  cup  of  hot  tea.  The  Germans  advise  lightly  boiled  eggs 
beaten  up  in  hot  broth.     They  also  use  eggs  in  coffee. 

Beef  juices,  beef  extracts,  meat  infusions,  and  all  the  long 
list  of  similar  articles  now  on  the  market  are  incontestably 
excellent  in  febrile,  acute,  and  in  many  other  conditions  ;  but 
they  are  often  abused.  I  believe  they  are  too  often  given  in 
a  too  concentrated  form  ;  that  then  they  stimulate  to  the  point 
of  irritation.  I  know  not  a  few  who  are  as  mentally  exhila- 
rated by  a  strong  cup  of  beef  tea  as  by  an  equal  quantity  of 
a  mild  sherry. 

Dilute,  then,  all  these  extracts ;  and,  further,  flavor  them 
with  the  expressed  juice  of  fresh  vegetables  (carrots,  parsnips. 


DIET  IN  DISEASE.  143 

etc.).     Sir  William  Jenner  thinks  the  vegetable  juices  a  most 
valuable  addition. 

It  will  often  be  found  beneficial  to  add  the  pulp  or  fine 
scrapings  of  meat  to  the  dilute  meat  extracts  or  clear  soups, 
and  this  is  best  in  those  cases  not  of  the  extremely  acute 
type. 

It  is  needless  to  say  that  calf's-foot  jelly,  rice  and  barley 
water,  chocolate  (deprived  of  fat),  "fruit  soups,"  oatmeal 
gruel,  and  the  like  are  all  of  them  good  substitutes  at  times 
for  some  ot  the  more  concentrated  foods. 

Malt  extracts  and  malted  foods  are  only  digested  starches. 
As  a  rule,  they  consist  of  ground  malt,  wheat  flour,  bicarbon- 
ate of  potash,  and  milk.  Fats  and  salts  are  not  well  repre- 
sented, or  at  least  sufiiciently  represented,  in  these  foods  ; 
hence  it  is  necessary  to  add  them. 

Pepsin,  the  proteolytic  ferment  of  the  gastric  juice,  is  too 
well  known  to  demand  more  than  the  passing  statement  that 
its  judicious  addition  to  food  in  acute  cases  is  frequently  a 
large  factor  in  restoration  to  health. 

Among  predigested  foods  foremost  stands  pancreatin  and 
peptonized  foods.  The  latter — artificially  digested  albumi- 
nates— are  highly  nutritious,  but  oftentimes  obnoxious  on  ac- 
count of  their  smell  and  taste.  So  many  pancreatic  extracts 
are  now  found  that  the  peptonized  foods  are  easily  made  in 
the  sick-room.  Peptonized  milk  and  peptonized  milk  gruel 
(according  to  Sir  William  Roberts's  rule)  are  excellent  pre- 
digested foods — perhaps  as  valuable  as  peptonized  beef  ex- 
tracts. 

A  form  of  extra  and  well-nigh  continuous  feeding  that  is 
popularly  known  as  "forced  feeding"  demands  attention. 
This  begins  by  the  patient  being  put  for  about  a  week  on  a 
milk  diet— three  or  four  ounces  every  two  hours,  increased  in 
a  few  days  to  two  quarts  in  twenty-four  hours,  given  in  di- 
vided doses.  Should  there  be  any  constipation,  a  mild  aloes 
pill  at  night,  or  a  cup  of  hot  coffee  on  waking,  may  be  given. 

At  the  end  of  a  week  they  are  permitted  a  light  breakfast, 
and  soon  are  given  three  good  meals  a  day  in  addition  to  two 


144  MEDICAL  GYNECOLOaY. 

quarts  of  milk  taken  at  or  between  meals.  At  this  time,  too, 
"raw  "  beef  soup,  to  wMch  has  been  added  a  small  quantity 
of  strong  hydrochloric  acid,  cocoa,  a  quantity  of  butter,  and 
perhaps  half  an  ounce  of  cod-liver  oil  after  each  meal,  with 
a  small  quantity  of  champagne.  Burgundy,  or  whisky. 

The  urine  must  often  be  examined  in  "forced-fed"  pa- 
tients ;  and  when  urates  begin  to  be  deposited  it  is  time  to  go 
back  to  the  simple  milk  diet  for  two  or  three  days,  or  to 
reduce  the  quantity  of  food.  Very  often  attacks  of  diarrhoea 
and  dyspepsia  may  attend  this  process  of  forced  feeding. 
They  are  usually  checked  by  immediately  administering  a 
half-diet. 

Debove's  "alimentation  f orcee "  is  to  introduce  by  the 
(Esophageal  tube  an  excess  of  food  into  the  stomach,  where 
this  excess  is  retained  and  digested,  while  previously  all  food 
was  rejected,  much  less  digested.  This  observer  states  that 
he  found  no  relationship  between  appetite  and  digestive 
power.  Powdered  raw  meat  (1,500  to  6,000  grains  a  day)  can 
be  given  best  through  the  oesophageal  tube,  and  this  is  the 
form  of  feeding  now  in  vogue  in  France. 

A  vegetable  diet  can  be  either  full  or  spare.  This  form  of 
diet  consists  principally  of  vegetables  and  fruits  and  a  modi- 
cum of  milk  and  eggs,  unless  an  absolutely  meager — "low  " — 
diet  is  demanded  so  as  to  obtain  a  certain  degree  of  starva- 
tion. When  this  last  is  required,  the  purely  vegetable  diet 
will  give  a  sufficient  bulk  of  food,  although  it  is  an  excessive 
tax  upon  all  the  organs  of  digestion,  especially  in  this  coun- 
try, where  aU  the  inhabitants  are  habituated  to  a  diet  in 
which  meat  plays  so  important  a  part. 

With  this  diet  patients  complain  and  suffer  much  from 
the  indigestion  that  ensues,  so  that  I  frequently  have  to  ad- 
minister diastase  (I  prefer  Forbes's)  in  order  to  relieve  this 
attendant. 

In  sexual  plethora  this  is  in  reality  an  advantage,  because 
the  desired  nonstimulating  effect  of  a  vegetable  diet  is  ob- 
tained, and  the  nerve  forces  and  thoughts  are  directed  from 
the  pelvic  organs  to  the  digestive  system.     Hence  a  little 


DIET  IN  DISEASE.  145 

indigestion  is  not  at  all  bad,  and,  if  not  the  pleasantest  of 
diversions,  it  becomes  at  least  a  beneficial  one. 

In  the  diet  now  under  discussion  there  are  certain  objec- 
tionable articles  for  those  of  feeble  digestion,  chiefly  the 
bulky,  watery  foods  without  much  of  the  nutritious  in  their 
composition,  such  as  cabbage  and  turnips.  Moreover,  articles 
rich  in  starch  can  not  be  given  to  such  patients,  for  fear  of  the 
results  of  excessive  fermentation.  This  last-named  variety  of 
food  can  not  be  given  to  those  who  have  much  more  adipose 
tissue  than  strength,  because  of  their  fat-forming  tendencies, 

A  spare  diet  may  consist  of  mixed  food  or  wholly  of  vege- 
tables. In  those  who  are  dyspeptic  and  feeble  the  mixed 
spare  diet  must  at  first  be  employed  ;  but  those  who  are  more 
robust  and  possess  fair  digestive  ability  are  not  to  haye  any 
animal  food.  The  great  point,  however,  is  the  limitation  of 
that  quantity  which  can  be  thoroughly  digested  and  assimi- 
lated both  primarily  and  secondarily. 

It  is  chiefiy  in  cases  of  oppression — often  mistaken  for 
exhaustion — where  rest  and  forced  feeding  do  so  much  more 
harm  than  good,  that  I  find  the  spare  diet  extremely  advan- 
tageous. 

Concerning  excrementitious  plethora,  all  that  has  just 
been  said  about  "low,"  "meager,"  or  "spare"  dieting  holds 
good,  save  that  in  the  majority  of  these  cases  I  permit  a  very 
limited  quantity  of  animal  food. 

So  often  is  excrementitious  plethora  allied  with  the  re- 
lated diatheses  of  gout,  rheumatism,  diabetes,  and  the  adipose 
tendency,  that  we  must  modify  the  diet  so  as  to  antagonize 
latent  conditions  whose  appearance  along  with  excrementi- 
tious plethora  would  amount  to  grave  complications. 

Finally,  there  are  certain  foods  that  must  be  omitted  from 
the  diet  of  the  sick  ;  but  it  is  exceedingly  difiicult  to  make  a 
list  of  articles  that  we  must  at  all  times  taboo. 

On  general  principles  I  should  advise  the  omission  of  veal, 
young  lamb,  pork  (save  in  small  quantities),  duck,  goose, 
fat  and  oily  fish  (especially  the  salmon  and  mackerel  species), 
cabbage,   cauliflower,   cucumbers,   and    turnips;    and    nuts, 


146  MEDICAL  GYNECOLOGY. 

dried  fruits,  or  those  fruits  that  are  too  richly  preserved  or 
seasoned. 

It  is,  however,  a  notorious  fact  that  very  many  things  that 
disagree  with  the  majority  act  quite  the  reverse  with  the 
minority ;  and  some  confirmed  dyspeptics,  who  suffer  after 
eating  the  most  wholesome  articles,  can  eat  veal,  cheese,  or 
pork  with  relish  and  advantage. 

I  begin  by  using  those  articles  that  are  wholesome  and 
digestible,  and  subsequently  carefully  extend  the  bill  of  fare, 
lastly  trying  the  more  doubtful  articles. 

Much  aid,  too,  is  given  by  the  history  of  special  cases. 
Nearly  every  one  not  mentally  or  physically  perverted  can 
pretty  accurately  tell  what  will  agree  or  disagree ;  and  though 
there  are  many  exceptions  to  it,  I  believe  this  rule  is  in  the 
main  correct  and  reliable :  what  one  craves  and  relishes 
usually  agrees,  unless  the  bad  habit  of  faulty  eating  has 
created  an  artificial  desire. 

It  is  beyond  the  scope  of  the  present  work  to  discuss  the 
value  of  the  grape  cure  in  abdominal  plethora  ;  the  Tcoumiss 
cure  in  tuberculosis  and  phthisis  ;  or  the  wTiey  cure  in  laryn- 
geal and  bronchial  diseases.  Nor  is  here  the  place  to  discuss 
in  detail  the  Banting  system^  on  the  diet  in  gout  or  in 
diabetes. 

For  obesity  many  diets  have  been  prepared,  but  they  all 
are  very  much  alike.  It  is  more  convenient  to  give  the  things 
to  be  avoided  than  to  give  those  that  should  be  used.  The 
fats,  sugar,  and  starch  should  be  avoided  altogether  or  used 
but  sparingly.  Fluids  of  all  kinds  should  be  used  in  small 
quantities.  Wine,  beer,  tea,  coffee,  cocoa,  and  chocolate  should 
not  be  used  at  all.  There  are  many  who  will  not  lose  flesh 
upon  any  kind  of  diet.  In  such  cases  exercise,  mental  and 
physical,  should  be  taken  in  connection  with  the  proper  diet. 

DIET   FOR  AGED   WOMEN. 

Food  should  be  given  five  or  six  times  a  day. 
Avoid  the  popular  error  of  giving  more  food  in  old  age  be- 
cause weakness  and  loss  of  flesh  are  noticed. 


DIET  IN   DISEASE.  147 

Milk  in  "  second  childhood  "  is  very  useful  and  should  be 
freely  given  unless  contraindicated  by  gastric  catarrh  or 
special  peculiarities. 

1.  On  rising.— W^irm  milk  with  lime  water,  or  a  glass  of 
hot  water  with  beef  extract  or  juice. 

2.  Breakfast. — Weak  tea,  milk,  fresh  eggs  lightly  cooked, 
a  chop  not  too  well  done,  stale  bread,  with  but  little  if  any 
butter. 

3.  Luncheon. — Oysters,  and,  if  no  meat  has  been  taken  for 
breakfast,  a  chop  or  piece  of  mutton,  an  ^^^.^  and  stale  bread, 
with  a  glass  of  sherry  ;  or  fresh  broth,  a  sandwich  of  grilled 
fowl  or  roast  beef,  a  glass  of  sherry  or  ale,  and  bread.  Fruit, 
such  as  grapes,  figs,  apples,  peaches,  or  the  like,  in  small 
quantity. 

4.  Dinner. — Light,  non-oily  fish,  mutton  or  beef  (rare), 
tripe,  birds,  baked  potatoes,  light  vegetables,  and  bread. 
Claret,  sherry,  or  brandy  and  soda. 

5.  Bedtime.  — Dry  biscuit,  with  milk  or  arrowroot  or  oat- 
meal gruel. 

Things  to  be  avoided  or  taken  sparingly  in  advanced  life. 

Use  sparingly. — Much  liquids  at  meals.  Broths  containing 
vegetables.  Butter  and  cheese.  Tea,  coffee,  cocoa  (best  taken 
an  hour  after  meals).     Fermented  liquors  often  disagree. 

Avoid. — Overdone  and  well-done  meat,  fresh  bread,  cab- 
bage, carrots,  turnips,  veal,  pork,  salt  meats,  pastry,  and 
salads ;  shellfish,  except  oysters,  lobsters,  crabs,  salmon,  eels, 
mackerel,  and  all  rich,  oily  fish. 


CHAPTER  XIII. 

MENTAL   THEEAPEUTICS   AJS^D   IJS^STITUTIOJSTAL   TKEATMENT. 
MENTAL  THERAPEUTICS. 

I  have  chosen  the  title  Mental  Therapeutics  for  the  subject 
of  such  remarks  as  may  seem  appropriate  in  this  connection. 

There  is  the  more  reason  why  this  subject  should  be  dis- 
cussed because  during  the  last  decade  considerable  attention 
has  been  given  to  it  by  some  of  the  most  scientific  men  in 
the  profession.  There  is  still  very  little  known  on  the  sub- 
ject, compared  with  what  should  be  in  order  to  utilize  this 
agency  more  fully  in  the  practice  of  medicine. 

From  the  very  beginning  of  the  healing  art  a  certain 
mental  or  psychological  power  or  influence  has  been  known 
and  exercised  in  curing  the  sick.  In  early  times  certain  men 
claimed  possession  of  a  divine  power  by  which  they  influ- 
enced other  minds  and  produced  appreciable  results.  Up  to 
the  beginning  of  the  Christian  era  this  was  believed  to  be  a 
divine  power.  After  that  it  lost  its  reputation  for  divine  ori- 
gin, and  was  supposed  to  be  a  form  of  witchcraft  having  its 
origin  with  the  Evil  One.  Within  the  past  century  scientific 
men  have  taken  up  the  subject  and  endeavored  to  place  it 
upon  a  scientific  basis.  Braide,  of  England,  and  Mesmer,  Lie- 
bault,  and  Charcot,  in  France,  have  done  much  in  these  mod- 
ern times  to  explain  this  mental  or  psychological  power  and 
to  render  it  useful  in  healing  the  sick.  By  these  investiga- 
tors certain  names  have  been  given  to  it — mesmerism,  after 
Mesmer ;  electrobiology,  by  Braide ;  and  by  the  French 
schools  of  Paris  and  IS'ancy  it  has  been  called  hj^pnotism, 
and  by  that  name  it  is  generally  known  in  the  profession  to- 

148 


MENTAL  THERAPEUTICS.  149 

day.  The  names,  however,  give  no  definite  idea  of  the  sub- 
ject. So  far  as  I  can  ascertain,  hypnotism  is  simply  a  certain 
influence  which  one  mind  has  or  can  exercise  over  another 
mind,  and  also  the  influence  of  one's  own  mind  upon  one's 
body. 

The  latest  explanation  of  this  interchangeable  mental  ac- 
tion or  influence  is,  that  each  being  possesses  two  minds,  one 
objective  and  the  other  subjective.  The  objective  mind  is 
the  one  which  brings  the  being  into  relation  with  things 
around  him— the  acting  and  reasoning  mind  in  relation  to 
environment.  The  other,  the  subjective  mind,  is  the  one  pos- 
sessing memory  and  extraordinary  powers  of  influencing  the 
body  and  in  communing  with  other  minds.  This  hypothesis, 
upon  which  hypnotism  or  mental  therapeutics  is  based,  may 
or  may  not  be  correct,  but  it  answers  the  purpose  of  enabling 
one  to  exiDlain  this  psychological  phenomenon  or  mental  ac- 
tion perhaps  better  than  any  other. 

This  peculiar  influence  of  one  mind  upon  another,  or  the 
communion  of  minds  one  with  another,  is  a  faculty  common 
to  all ;  but  some  have  it  in  such  a  limited  degree  as  to  be 
unnoticeable,  while  in  others  it  is  possessed  to  an  extraordi- 
nary degree.  The  method  of  communication  difi'ers  from  the 
ordinary  means  in  the  fact  that  the  transference  of  impres- 
sions or  influences  from  one  mind  to  another  may  take  place 
without  any  of  the  physical  means  of  communication,  such 
as  spoken  words,  facial  expressions,  or  gestures. 

This  power  has  long  been  recognized  and  has  been  em- 
ployed in  the  practice  of  medicine,  and  every  one  who  has 
given  any  attention  to  the  subject  knows  that  such  an  in- 
fluence is  possessed.  Some  medical  men  possess  it  in  a  high 
degree,  others  scarcely  at  all.  Those  who  are  noted  for  their 
ability  in  this  direction  are  spoken  of  as  being  very  magnetic, 
or  possessing  wonderful  tact  in  flrst  attracting  the  attention 
of  patients  and  concentrating  their  thoughts,  then  gaining 
their  confidence  and  rendering  them  subservient  to  the  will  of 
the  practitioner. 

This  ability  to  inspire  confidence  and  obtain  control  over 


150  MEDICAL  GYNECOLOGY. 

patients  is  the  mental  therapeutics  of  every-day  practice,  and 
to  that  extent,  when  employed  in  its  highest  perfection,  is  of 
much  possible  value. 

The  way  in  which  this  mental  influence  operates  is  said 
to  be  by  suggestion.  The  operator  thinks  earnestly  and 
strongly  desires  to  impress  a  certain  thought  upon  another 
mind,  and  it  is  communicated  by  what  is  known  as  telepathy, 
or  the  transference  of  ideas.  It  may  be  done  orally  by  stat- 
ing in  a  positive,  confident  manner  that  another  will  do  or 
believe  a  certain  thing.  This  is  sufiicient  to  direct  the  mind 
of  the  percipient  in  a  certain  channel,  and  his  mind  acts  ac- 
cordingly. 

It  is  claimed  that  this  suggestion — telepathy,  or  mind  in- 
fluence— acts  much  more  effectively  in  sleep.  Hence,  to  prac- 
tice mental  therapeutics  in  its  highest  integrity,  it  is  neces- 
sary to  produce  a  certain  form  or  degree  of  sleep  in  the  sub- 
ject to  be  acted  upon.     Therefore  the  patient  is  hypnotized. 

There  are  various  ways  of  producing  this  hypnotic  sleep, 
and  there  are  also  several  degrees  of  the  state.  Mesmer 
hypnotized  his  subjects  by  gazing  steadfastly  into  their  eyes 
and  making  certain  passes  with  the  hands  over  the  head,  and 
when  they  became  drowsy,  suggesting  to  them  that  they  were 
asleep,  or  would  go  to  sleep,  by  telling  them  so.  This  gave 
rise  to  the  belief  that  the  hypnotic  sleep  was  produced,  and 
indeed  that  all  the  influences  were  produced  by  a  certain 
animal  magnetism  or  magnetic  fluid  which  was  communi- 
cated from  the  operator  to  the  patient.  Braide  and  others 
discovered  that  the  hypnotic  sleep  could  be  caused  by  the 
patient  fixing  his  eyes  upon  a  bright  object,  and  by  sugges- 
tions of  the  operator  that  he  would  go  to  sleep.  Others  have 
succeeded  by  suggestion  alone,  like  Liebault,  who  produces 
the  hypnotic  sleep  by  oral  suggestion,  simply  telling  the 
patient  that  if  he  will  make  up  his  mind  to  go  to  sleep  he 
will,  and  then  repeating  that  he  is  going,  and  that  he  has 
gone,  to  sleep. 

There  are  different  degrees  of  this  hypnotic  sleep.  These 
are  known  as  the  cataleptic  state,  the  lethargic  state,  and  the 


MENTAL  THERAPEUTICS.  151 

somnambulistic  state.  These  seem  to  be  but  different  degrees 
of  the  same  sleep,  and,  so  far  as  scientists  have  yet  discovered, 
there  is  no  known  difference  between  the  hypnotic,  or  the 
sleep  produced  by  the  will  of  the  hypnotizer,  and  natural 
sleep,  which  comes  in  the  ordinary  way  ;  and  quite  recently 
it  has  been  stated  that  in  natural  sleep,"  not  produced,  the 
mental  influences  by  suggestion  or  telepathy  can  be  exercised 
just  as  well  as  in  a  produced  sleep — hypnotic  state. 

The  question  which  specially  concerns  us  at  the  present 
time  is,  In  what  way  can  this  mind  influence,  exercised  when 
the  subject  is  asleep  or  hypnotized,  be  made  effectual  in  curing 
disease  ?  Accepting  the  idea  that  one  in  this  condition  is  so 
under  the  control  of  the  physician  or  operator  that  his  mind 
can  believe  anything  suggested  to  it,  and  can  make  extraor- 
dinary efforts  to  accomplish  any  object  or  end  suggested,  it 
is  evident  that  the  innervation  of  any  of  the  physical  struc- 
tures can  be  greatly  modified  by  this  influence.  It  is  a  known 
fact  that  if  one  is  under  the  psychological  or  mental  influence 
of  another,  especially  in  the  hypnotic  state,  and  the  operator 
suggests  to  the  patient  to  change  the  circulation  in  a  given 
part  of  the  body,  the  blood  supply  will  be  modified  accord- 
ingly. By  suggesting  to  one  who  is  hypnotized  that  a  given 
part  of  the  body  is  burning,  it  will  become  strongly  con- 
gested. In  fact,  it  is  claimed  that  blisters  have  been  raised 
in  this  condition  and  by  this  mental  influence.  Such  being 
the  case,  if  a  hyj)notized  patient  has  the  suggestion  made  that 
an  organ  or  tissue  of  the  body  in  which  there  is  deranged  cir- 
culation, probably  arising  from  deranged  innervation,  will  be 
relieved,  the  mind  of  the  patient  will  so  adjust  the  innerva- 
tion of  the  organ  or  tissue  as  to  give  relief.  In  this  respect 
hypnotism  or  mind  influence  is  one  of  the  most  powerful 
agents  in  curing  functional  diseases. 

All  diseases,  then,  that  are  not  organic  can  be  relieved, 
oftentimes  cured,  by  this  mental  influence  or  mental  thera- 
peutics. It  is  limited,  I  believe,  to  just  that  class  of  diseases. 
It  would  be  a  waste  of  time  to  enumerate  them,  because  they 
wiU  readily  occur  to  the  reader. 


152  MEDICAL  GYNECOLOGY. 

It  may  be  claimed— in  fact  is  claimed — by  tlie  advocates 
of  this  hypnotism  or  mental  therapeutics  that  organic  dis- 
eases can  also  be  cured.  That,  of  course,  would  greatly  de- 
pend uj)on  the  character  of  the  organic  disease  and  the  extent 
of  its  progress.  It  is  fair  to  say  that  any  organic  disease  that 
is  not  curable  by  any  of  the  ordinary  kno^Yn  agencies  or  the 
ordinary  vital  recuperative  forces  would  not  be  at  all  aided  or 
relieved  by  hypnotism  or  mental  therapeutics. 

There  is  another  question  which  arises,  and  one  that  I 
think  has  not  yet  been  settled,  and  that  is  :  Can  anything  be 
done  by  mental  therapeutics  that  can  not  be  done  by  other 
means  and  just  as  well  ?  To  this  I  may  say  that  if  there  are 
any  such  diseases  curable  in  such  way,  they  are  exceedingly 
limited,  and  they  are  only  curable  by  mental  therapeutics 
when  they  occur  in  certain  organizations,  imaginative  and 
hysterical  subjects  especially. 

Another  question  is.  Does  not  the  mental  wear  and  tear  of 
the  patient's  mind  in  acting  upon  matter,  with  a  view  to  re- 
lieving morbid  states,  do  as  much  harm  as  the  effort  at  cur- 
ing or  relieviDg  does  good  ?  I  think  that  in  the  majority  of 
cases  the  exhaustion  of  the  nervous  system  is  not  marked, 
and  that  one  can  be  placed  in  the  hypnotic  state,  or,  as 
some  have  the  power  to  do,  can  hypnotize  themselves  without 
much  exhaustion  apparently  following. 

I  therefore  fully  believe  in.  and  have  long  practiced,  this 
mental  therapeutics,  so  far  as  suggestion  is  concerned.  Every 
physician  knows  that  if  he  can  only  get  his  patients  to  co- 
operate with  him  in  the  management  of  their  diseases  they 
do  better.  "Faith  is  half  the  battle  in  the  cure  of  disease" 
is  an  old  saying  that  all  believe,  in  part  at  least,  and  no 
doubt  it  is  true.  If  a  patient,  through  the  confidence  he 
places  in  his  physician  and  through  the  strong  mental  power 
of  the  physician,  is  fully  persuaded  that  he  is  going  to  re- 
cover, he  will  certainly  have  greatly  improved  innervation 
— that  innervation  which  plays  such  an  important  part  in 
maintaining  health  and  in  the  relief  of  certain  morbid  con- 
ditions.    And  certainly  it  can  be  judiciously  stated  that 


MENTAL  THERAPEUTICS.  153 

mental  therapeutic  agencies,  if  brought  to  act  in  connec- 
tion with  other  means  of  curing  disease,  possess  very  great 
value. 

That  mental  therapeutics  or  mind  curing  is  exceedingly 
limited  and  is  imperfectly  understood,  and  is  far  from  accom- 
plishing all  that  is  claimed  for  it  by  its  enthusiastic  advocates 
outside  the  profession,  must  be  accepted  as  fact.  Scientific 
men  of  the  profession  who  have  employed  this,  and  who  have 
obtained  remarkable  results  in  the  cure  of  functional  dis- 
eases, claim  nothing  extraordinary. 

This  leads  me  to  say  a  word  with  reference  to  the  use  of 
mental  therapeutics  or  hypnotism  by  the  laity,  who  call  it 
"Christian  Science,"  "Faith  Cure,"  "Mind  Cure,"  and  the 
like. 

This  popular  cure,  as  practiced  by  the  laity,  is  little  more 
or  less  than  a  craze,  which  has  come  to  do  some  good  and 
much  harm  for  a  time,  and  then  to  disappear,  as  all  things  of 
the  kind  have  done. 

In  order  to  deal  fairly  with  those  among  the  laity  who 
practice  the  healing  art  in  this  way,  it  must  be  said  that  some 
of  them,  no  doubt,  have  acquired  the  faculty  of  doing  good 
by  means  of  this  mental  influence.  I  presume  that  the 
"  Christian  scientists  "  accidentally  stumbled  upon  this  hyp- 
notic influence  or  power,  and  some  effects  in  the  healing  of 
the  sick  were  observed,  and  they  continue  to  practice  in  black 
darkness,  hoping  to  accomplish  great  things  in  the  cure  of  all 
diseases.  A  sad,  pitiful  show  they  make  of  themselves  when 
trying  to  do  impossible  things.  While  they  are  doing  an 
endless  amount  of  harm,  they  do  good  occasionally ;  but  it 
is  by  accident.  When  by  chance  they  get  hold  of  a  case 
that  can  be  relieved  by  hypnotic  suggestion,  and  they  suc- 
ceed in  hypnotizing  the  sufferer,  they  may  do  good.  But 
the  harm  they  do  far  outbalances  the  good  in  their  efforts  to 
do  impossible  things  by  using  their  faith  cure  in  cases  that 
can  not  be  helped  by  it,  and  by  keeping  the  poor  sufferers 
from  proper  treatment.  They  offend  against  the  right  in  this 
way,  as  all  charlatans  do,  by  insisting  on  being  able  to  cure 


154  MEDICAL  GYNECOLOGY. 

all  diseases  by  one  agent,  tlie  power  of  wMch.  is  very  limited 
and  only  applicable  to  a  few  diseases.  They  should  be  sup- 
pressed. Who  would  dare  to  permit  an  ignorant  person  to 
operate  in  surgical  cases  simply  because  that  one  had  the  im- 
pertinence to  suppose  he  was  a  surgeon  ? 

If  these  faith  curists,  Christian  scientists,  or  whatever 
they  may  be  called,  understood  hyj^notism  and  could  use  it 
under  the  direction  of  a  physician  who  could  give  them  se- 
lected cases  and  direct  them  how  to  do,  they  might  be  of 
some  service,  just  as  those  who  give  massage  or  gymnastic 
exercises  can  relieve  suffering.  But  as  they  are  and  as  they 
practice  they  are  a  bane  to  the  world.  In  order  to  get  rid  of 
them,  the  medical  profession  must  point  out  their  true  po- 
sition, giving  them  credit  for  the  good  that  is  in  them,  and 
condemning  justly  their  wrongdoings. 

Those  who  with  good  intent  try  to  cure  the  sick  by  prayer 
do  good,  and  are  helpful  in  certain  cases.  Prayer  is  a  thera- 
peutic agent ;  the  hypnotic  state  can  be  induced  by  prayer, 
and  when  employed  in  proper  cases  and  including  the  right 
suggestion,  is  a  curative  agent  of  value  in  certain  diseases. 
An  earnest  prayer  for  a  given  person  may,  through  mental 
influence  and  suggestion,  relieve  that  person.  If  relief  is 
sought  in  prayer,  and  it  is  possible  that  it  can  be  obtained 
through  hypnotism,  that  prayer  will  be  answered.  The  laws 
of  psychology  and  physiology  are  so  arranged  that  certain 
prayers  are  answered  and  others  are  not.  This  is  the  only 
scientific  explanation  of  the  efficacy  of  prayer  in  healing  the 
sick  that  I  can  find. 

When  Tyndall  proposed  to  try  the  treatment  of  a  certain 
number  of  patients  in  a  hospital  with  prayer,  and  an  equal 
number  in  the  usual  way,  in  order  to  ascertain  the  value  of 
prayer  in  the  healing  of  the  sick,  he  was  denounced  by  many 
good,  well  meaning  men,  and  called  a  scoffer  and  an  unbe- 
liever. I  am  sure  that  he  was  neither.  He  was  only  seeking 
the  truth.  Medical  men  know  very  well  that  prayer  is  with- 
out avail  in  some  diseases,  and  believers  are  equally  sure  that 
prayer  is  able  to  aid  in  the  cure  of  disease.     Both  are  right 


INSTITUTIONAL  TREATMENT.  155 

to  a  limited  extent.  Prayer  is  a  means  of  producing  a  mental 
state,  in  whicli  certain  suggestions  become  active  and  modify 
the  innervation  and  circulation  in  diseased  organs  and  tissues 
of  the  body.  Physical  changes  must  necessarily  follow,  and 
certain  affections  are  cured  thereby  as  surely  as  by  drugs  or 
anything  else. 

But  all  this  that  we  hear  about  the  marDelous,  the  won- 
derful, the  Tniraculous  cures  that  are  produced  by  the  ig- 
norant practitioners  of  faith  cure  or  Christian  science,  or 
mind  cur^,  has  so  little  in  it  that  it  is  hardly  worth  the  atten- 
tion of  any  medical  man.  They  know  nothing  of  what  they 
are  doing  or  how  they  do  it ;  and  because  some  cases  recover 
that  they  treat  in  their  own  peculiar  way,  they  are  encour- 
aged to  believe  that  they  are  omnipotent. 

I  have  carefully  watched  this  practice  among  the  laity, 
and  have  honestly  endeavored  to  give  them  credit  for  all  that 
they  deserve,  and  I  am  bound  to  say  that  I  have  found  noth- 
ing of  the  wonderful,  marvelous,  and  miraculous,  except  the 
failures  which  they  make,  as  a  rule,  with  an  occasional  suc- 
cess ;  so  that  the  good  they  do  is  buried  out  of  sight  under 
a  heap  of  mischief. 

THE    MANAGEMENT  OF    DISEASES    OP   WOMEN    IN    INSTITU- 
TIONS  DESIGNED  FOR  THAT  PURPOSE. 

In  discussing  the  institutional  treatment  of  the  sick  I 
desire  to  have  it  distinctly  understood  that  I  refer  only  to 
such  private  hospitals  as  are  constructed  upon  the  most 
scientific  principles  and  conducted  by  those  who  look  fully 
to  the  highest  interests  of  patients  committed  to  their  care. 
Boarding  houses  managed  on  a  commercial  basis  are,  as  a 
rule,  inferior  to  home  for  those  who  are  ill. 

To  carry  out  a  systematic  course  of  treatment,  in  chronic 
cases  especially,  is  always  difficult — sometimes  impossible — 
in  private  practice.  It  is  hard  to  obtain  the  necessary  seclu- 
sion, rest,  and  control  in  a  private  house  amid  family  sur- 
roundings.    IN'owadays  a  competent  nurse  can  be  obtained, 

but  home  and  family  interests  and  the  interference  of  rela- 
11 


156  MEDICAL  GYNECOLOGY. 

tives  and  friends  thwart  the  efforts  of  physician  and  nurse  in 
carrying  out  that  which  is  requisite  and  necessary. 

Those  who  have  had  experience  in  the  management  of  dis- 
eases of  long  standing  and  in  surgical  cases  know  very  well 
that  they  can  have  better  treatment  in  proper  institutions 
than  in  private  houses.  This  has  been  fully  demonstrated, 
and  the  tendency  of  the  present  age  appears  to  be  more  and 
more  toward  the  establishment  and  encouragement  of  such 
institutions. 

There  is  among  the  people  still  some  prejudice  against  in- 
stitutions for  the  care  of  tbe  sick,  but  this  arises  from  the 
fact  that  such  places  have  been  used  in  the  past  for  the  poor 
only.  The  very  poverty  of  such  hospitals  has  often  led  to 
misusage  in  overcrowding,  poor  feeding,  poor  nursing,  and 
so  on.  But  the  principle  of  having  institutions  for  the  care 
of  the  sick  is  sound.  Xow  that  there  are  proper  places  for 
the  care  of  the  sick,  the  rich  and  intelligent  are  beginning  to 
see  the  advantages  of  them.  There  are  certainly  as  good  rea- 
sons for  rich  and  intelligent  parents  to  send  their  sons  or 
daughters  to  Institutions  for  the  treatment  of  disease,  or  to 
schools  for  physical  culture,  as  to  send  them  to  boarding 
schools  for  education. 

The  advantages  of  such  institutions  are  many.  They  can 
be  constructed  uj)on  the  best  sanitary  princiiDles  and  adapted 
to  the  wants  of  the  sick.  The  progress  in  sanitary  archi-- 
tecture  made  in  recent  times  makes  it  x3ossible  to  construct 
a  building  which  will,  to  a  large  extent,  guard  the  inmates 
from  the  causes  of  disease  which  are  generated  by  their  own 
eliminations.  Such  a  building  can  also  be  adapted  to  the 
requirements  and  comforts  of  the  sick.  A  house  suited  for 
a  family  home  is  not  well  adapted  to  the  accommodation  of 
patients.  The  order  and  government  of  such  a  hospital  can 
be  made  agreeable  to  the  suffering  inmates,  both  as  regards 
quiet  and  also  cleanliness,  which  include  sewerage  and  venti- 
lation. Diet  also  can  be  regulated  according  to  the  laws  of 
health,  and  made  agreeable  and  tempting  to  the  capricious 
appetites  of  patients.     When  the  sole  object  of  the  establish- 


INSTITUTIONAL  TREATMENT.  157 

ments  is  to  improve  tlie  health  of  those  who  dwell  in  them, 
and  where  the  physician  and  surgeon  and  their  attendants 
have  the  controlling  power,  a  condition  of  hygiene  is  secured 
which  is  all  bnt  impossible  in  a  private  family. 

In  such  an  establishment  the  doctor  has  great  advantages. 
His  patients  being  brought  together,  he  can  attend  a  larger 
number  in  a  shorter  time.  He  has  also  a  more  perfect  control 
of  all  their  doings.  In  this  country  and  in  Europe  we  find 
that  the  foremost  men  among  specialists  have  their  private 
institutions  for  the  care  of  their  patients.  That  such  institu- 
tions are  successful  and  advantageous  to  patients  and  physi- 
cian is  a  fact  beyond  all  question.  That  more  of  them  are 
needed  is  also  a  fact,  the  proof  of  which  is  found  in  another 
fact — viz.,  the  prosperity  of  institutions  under  the  care  of  half- 
educated  men  who  practically  carry  out  but  one  idea  in  the 
treatment  of  diseases,  like  hydropathic  and  cancer  cure  es- 
tablishments, for  example.  For  many  years  such  places  have 
been  crowded  by  invalids  in  search  of  health.  Rather  than 
waste  energy  in  declaiming  against  such  places,  it  would  be 
better  for  the  profession  to  recognize  the  good  that  is  in  them 
and  erect  institutions  upon  proper  scientific  principles  to  take 
the  place  of  those  which  have  for  a  long  time  been  the  only 
resorts  open  to  responsible  sick  people. 

There  is  still  another  argument  in  favor  of  such  institu- 
tions, and  that  is,  the  progress  in  the  science  and  art  which 
has  been  made  in  hospitals  in  the  past  history  of  the  world. 
Much  of  all  that  is  valuable  in  medicine  and  surgery  has 
originated  in  hospitals  and  charity  institutions.  The  Women's 
Hospital  and  other  institutions  in  iJ^ew  York,  for  example, 
have  given  more  to  the  surgery  of  gynecology  than  all  the 
private  practitioners  in  the  world.  This  statement,  which  is 
rather  sweeping,  is  not  intended  to  take  from  the  honor  due 
to  those  who  are  wholly  engaged  in  private  practice.  Those 
who  have  hospitals  at  their  command  have  no  more  brains 
than  those  who  have  not,  but  the  advantages  of  the  one  class 
afford  the  opportunities  of  developing  new  ideas  in  practice 
which  can  not  be  obtained  in  private  practice — at  least  to  the 


158  MEDICAL  GYNECOLOaY. 

same  extent.  The  history  of  medicine  and  surgery  abundant- 
ly shows  that  the  leaders  in  the  profession  have  been  men 
who  enjoyed  the  advantage  of  hospital  practice.  True,  the 
hospitals  in  which  these  men  have  labored  have  been  charity 
institutions,  many  of  them  poorly  adapted  to  the  wants  of 
patients.  In  fact,  at  the  present  time,  many  of  our  hospitals 
are  so  poor  that  the  physicians  and  surgeons  are  hampered  in 
their  efforts,  and  still  the  results  obtained  are,  in  many  cases, 
equal  or  superior  to  those  obtained  in  private  practice.  In  our 
best  charity  hospitals  the  patients  obtain  better  chances  than 
the  rich  do  in  their  luxurious  homes.  It  is  now  surely  true 
that  the  rich,  or  well-to-do  people,  who  are  able  to  pay  for 
proper  care  when  they  are  sick,  should  have  the  advantages 
which  the  poor  irresponsibles  enjoy. 

This  argument  may  call  up  the  counter-statement  that 
there  are  dangers  in  hospitals  unknown  in  private  houses. 
This  is  true  of  some  hospitals.  The  crowding  together  of  all 
kinds  of  diseases  and  injuries  in  rooms  that  are  too  small  and 
badly  constructed  tends  to  develop  and  spread  diseases  ;  but 
in  structures  built  upon  sanitary  principles,  in  which  diseases 
and  injuries  are  properly  classified,  all  these  dangers  can  be 
avoided. 

We  have  health  resorts,  so  called,  where  the  sick  may  go 
in  summer  and  winter,  but  they  are  mostly  away  from  the 
cities  and  out  of  the  reach  of  those  who  most  need  them. 
They  are  also  under  the  control  of  hotel  keepers,  who  can  not 
make  their  houses  to  fully  suit  the  demands  of  the  really  sick. 
In  discussing  general  therapeutics  it  seems  proper  and  right 
to  say  a  word  in  favor  of  institutions  in  our  cities  under  the 
management  of  responsible  members  of  the  medical  profes- 
sion, in  which  those  who  need  special  care  can  have  all  that 
science  and  art  can  afford  them. 


CHAPTEE  Xiy. 

METHODS   OF   EXAMINING  PATIENTS. 

The  art  of  taking  a  history  with  a  view  to  diagnosis,  the 
varied  methods  of  examination  of  patients,  the  modus  or 
technique  of  inspection,  palpation,  percussion,  auscultation, 
and  mensuration,  and  their  valuation  when  associated  with 
symptoms  given  us  by  the  patients  themselves  (rational  or 
subjective  symptoms),  are  all  fully  discussed  in  text-books  on 
medicine,  surgery,  and  special  treatises  on  physical  diag- 
nosis. 

In  every  systematic  description  of  a  disease  the  physical 
signs  are  given,  frequently  forming  the  sole  data  upon  which 
a  certain  diagnosis  can  be  made.  Nowhere  else  are  physical 
signs  so  important  as  in  diseases  of  women,  although  here 
it  is  unnecessary  to  enter  into  an  elaborate  discussion  of  the 
elementary  portion  of  the  subject. 

It  is  taken  for  granted  that  my  readers  are  fully  conver- 
sant with  the  rudiments  of  physical  investigation,  but  it  can 
not  be  too  thoroughly  impressed  that,  to  be  a  skilful  diag- 
nostician in  a  special  branch,  one  must  have  a  complete  and 
rigid  drill  in  general  diagnosis. 

It  is  not  possible  to  distinguish  with  surety  any  disease 
of  the  sexual  organs,  and  to  observe  its  relations  with  and 
dependence  upon  the  general  system,  without  being  an  expert 
in  general  investigation.  There  are,  however,  certain  definite 
principles  which  should  guide  the  physician  in  his  investi- 
gations in  women's  diseases. 

Hence  that  method  for  obtaining  information  and  the  ex- 
planations for  utilizing  such  information  must  be  of  prime 

159 


IQQ  MEDICAL  GYNECOLOGY. 

consideration  in  the  present  work.  I  feel  that  the  best  plan 
is  that  which  can  simplify  and  classify  methods  of  observa- 
tion ;  which,  at  the  same  time,  affords  the  best  deductions 
adapted  to  the  gynecologist. 

The  method  that  I  f  oUow  is  one  that  seems  to  me  straight- 
forward and  logical,  beginning  as  it  does  with  the  most 
general  view  of  woman,  and  narrowing  down  until  the  spe- 
cific disorder— should  there  be  one— is  discovered. 

First,  the  examiner  should  have  in  mind,  a  typical  woman 
—a  woman  who  is  healthy  ;  and  I  believe  that  every  one- 
student  and  physician— should  acquire  the  power  to  detect 
all  the  evidences  of  a  sound  organization  in  a  healthful 
state. 

Secondly,  the  temperament  should  next  be  discovered, 
for  upon  its  full  comprehension  much  depends,  especially  as 
concerns  the  prognosis  and  treatment.  In  the  examination 
of  patients  I  prefer  to  keep  in  mind  the  classification  of 
temperament  as  indicated  by  structure— i.e.,  the  sanguine, 
nervous,  phlegmatic,  and  motor  or  muscular.  Temperament 
indicates  a  liability  rather  than  a  predisposition  to  certain 
diseases.  The  subjects  of  nervous  temperament  are  more 
prone  to  diseases  of  the  nervous  system ;  the  muscular  or 
motor  to  diseases  and  injuries  of  the  muscular  system,  and 
so  on. 

The  diagnosis  of  the  predisposition  to  disease,  by  reason 
of  imperfect  or  abnormal  structure,  depends  so  much  upon 
the  temperament  that  the  necessity  of  obtaining  a  distinct 
notion  in  one's  own  mind  as  to  what  particular  class  the 
patient  should  be  placed  in  is  well-nigh  self-evident. 

Predisposition  to  disease  is  frequently  discovered  by  in- 
quiry as  to  the  past  life.  At  times  the  immediate  family  can 
give  us  data,  especially  in  the  line  of  hereditary  tendency  ; 
but  still  I  believe  that  the  general  character  of  predisposition 
is  greatly  determined  by  the  temperament  which  has  already 
been  discussed  at  length. 

Age  as  a  factor  in  causation,  prognosis,  and  treatment  is 
a  point  never  to  be  neglected  in  a  physical  examination,  for. 


METHODS  OF  EXAMINING   PATIENTS.  161 

we  can  call  it  physical,  even  if  elicited  by  questioning  from 
the  patient.  I  do  not  mean  by  age  the  number  of  years  that 
have  elapsed  since  birth,  but  rather  the  general  bodily  con- 
dition, vs^hether  youthful,  active,  or  senile.  The  examiner 
should  remember  how  foolhardy  it  is  to  seek  roses  in  Novem- 
ber or  ice  in  June, 

Fourthly,  all  evidence  of  disease  should  next  be  gathered ; 
general  or  constitutional  conditions  should  be  looked  for, 
and  subsequently  local  lesions  or  derangements  can  be  the 
subject  ot  search. 

There  are  many  diatheses  or  dyscrasise — the  gouty,  the 
rheumatic,  the  strumous,  the  fibroid,  the  diabetic,  the  hsemor- 
rhagic,  the  neuropathic,  the  psychotic,  and  the  tuberculous — 
all  of  which  have  manifestations  now  prominent  and  unmis- 
takable, again  subtle  and  evasive.  Moreover,  they  are  inter- 
changeable. I  have  seen  gouty  parents  have  rheumatic  off- 
spring, who  in  turn  had  children  who  were  enormously  fat  • 
and  the  progeny  of  the  latter  diabetic. 

I  have  seen  the  rheumatic,  gouty,  and  fibroid  diatheses 
intermingle  and  interchange.  The  rheumatic  and  the  neuro- 
pathic sometimes  combine,  but  more  often  do  the  psychotic 
and  neuropathic  become  allied. 

The  JicBmorrhagic  diathesis  is  one  where,  in  childhood, 
black  and  blue  spots  often  appear  quite  independent  of  any 
bump  or  bruise,  where  excessive  bleeding  followed  trivial 
wounds  or  blows,  and  where,  after  puberty,  menorrhagia 
thrives.  Hsemophlles,  as  they  are  called,  are  usually  fat, 
have  an  abnormally  small  heart,  and  are  quite  often  chlorotic. 

Those  of  a  gouty  diathesis  have  acid  urine  and  perspira- 
tion, are  generally  of  a  full  habit,  with  a  good  deal  of  flesh, 
have  a  persistent  plethora  of  the  digestive  organs,  and  their 
kidneys,  as  a  rule,  act  imperfectly.  Despite  these  evidences, 
the  diathesis  is  not  always  recognizable. 

Those  of  a  rJieumatie  diathesis  have  an  excess  of  fibrin  (or 
fibrin  factors)  and  lactic  acid  in  the  blood.  We  can  best 
make  out  this  diathesis  by  eliciting  their  hereditary  history 
and  by  questioning  those  who  know  them  concerning  former 


IQ2  MEDICAL  GYNECOLOGY. 

attacks.  Very  often  the  exact  diagnosis  is  made  only  by  an 
examination  of  the  state  of  the  blood.  Eheumatism  is  often 
caused  by,  occurs  with,  or  follows  the  puerperal  state  and 
diseases  of  the  sexual  organs. 

The  jibroid  diathesis  has  much  in  common  both  with  the 
gouty  and  with  the  rheumatic.  Perhaps  an  abnormally  per- 
sistent, tense  pulse  and  prematurely  hard  arteries  might  lead 
us  to  anticipate  the  diagnosis,  which,  however,  can  only  be 
made  out  when  the  heart  has  undergone  hypertrophy  and 
the  kidneys  have  become  cirrhotic.  This  occurs  later  in  life, 
usually  about  the  time  of  the  menopause. 

The  scrofulous  is  closely  connected  with  the  tuberculous 
diathesis.  The  glands  are  chiefly  involved.  Scrofulous  sub- 
jects have  a  light,  fair  complexion,  often  of  a  waxy  hue ;  they 
are  pale  and,  as  a  rule,  fleshy.  The  mucous  membranes  are 
well-nigh  bloodless,  soft,  and  irregular.  The  tonsils  are  en- 
larged, or  have  a  marked  tendency  to  enlargement.  The 
lymphatic  glands,  especially  those  of  the  maxillary  region, 
enlarge  and  are  prone  to  suppurate.  Their  teeth  are  poor 
and,  as  a  rule,  long.  The  head  is  large— notably  so— and  the 
eye  is  clear.  During  infancy  and  childhood  they  have  fre- 
quent "sore  throat"  and  attacks  of  bronchitis.  Very  often 
they  exhibit  evidences  of  anaemia  and  have  acute  attacks  of 
indigestion. 

The  tuberculous  are  thin ;  their  blood-corpuscles  are  de- 
flcient  in  every  way ;  their  heads  narrow  at  the  base  and 
quite  long ;  they  have  a  nervous  or  intellectual  temperament, 
and  are  "quick"  in  studies  but  "delicate."  Their  lower  jaw 
is  long,  thin,  and  pointed,  the  features  are  small  and  well 
defined,  the  nostrils  thin,  and  usually  they  have  blue  eyes. 
They  seldom  in  early  life  have  lung  evidences  of  disease, 
and  their  chief  general  characteristics  resemble  those  of 
scrofulous  children. 

The  diathesis  is  not  of  so  great  value  in  the  diagnosis  as 
in  the  prognosis,  since  all  diathetic  individuals  are  liable  to 
disease  of  the  sexual  organs,  and  when  this  last  does  occur, 
the  latent  disease — or  diathesis — then,  and  then  only,  appears 


METHODS  OF  EXAMINING  PATIENTS.  163 

with  peculiar  complications  which  are  very  apparent  and  at 
times  diagnostic. 

The  local  evidences  of  disease  are  legion.  Here  the  thor- 
oughness and  individuality  of  the  examiner  must  come  in. 
No  rule  can  be  laid  down  that  will  make  a  man  thorough  and 
alert. 

The  jifth  point  to  determine  is  whether  the  local  condition 
— if  any  exist — merely  preceded  the  constitutional  disorder  ; 
whether  it  preceded  and  caused  it  too ;  whether  it  followed 
it  as  a  restlt  or  not ;  in  short,  to  determine  what  is  the  inter- 
dependence of  the  local  and  general  conditions. 

The  sixth  point  in  the  system  that  I  adopt  when  making  a 
physical  examination  concerns  the  specific  symptoms  of  dis- 
eases of  the  sexual  organs.  It  is  at  this  point  that  the  diag- 
nostic field  narrows  down  from  general  to  local ;  and  it  is 
perhajDs  at  this  j)oint  also  that  the  knowledge  of  the  specialist 
comes  prominently  into  evidence. 

However  unreasonable,  however  inexplicable,  the  fact 
nevertheless  confronts  us  that  the  only  maladies  women  are 
ashamed  of  are  those  of  the  sexual  organs  ;  hence  the  tactical 
and  diplomatic  investigator  has  in  this  line  of  practice  an 
immense  advantage  over  him  whose  attack  is  brutal  and 
direct. 

Since  the  symptoms  are  given  in  connection  with  each 
case  and  disease,  I  shall  here  only  offer  suggestions  concern- 
ing the  method  or  technique  of  the  examinations,  endeavor- 
ing to  clearly  show  how  to  make  full  use  of  all  the  data  thus 
obtained  for  the  determination  of  the  diagnosis. 

The  order  of  examination  should  be  inspection^  palpation^ 
percussion,  auscultation,  and  mensuration,  and  the  phys- 
ical signs  in  health  and  disease  of  all  the  organs  of  the  body 
should  be  well  understood  by  the  physician  who  practices 
gynecology.  It  is  not  enough  to  detect  disease  of  the  sexual 
organs ;  one  must  determine  the  condition  of  the  whole  or- 
ganization in  order  to  decide  regarding  the  general  health  as 
affected  by  the  local  disease,  complicating  diseases,  or  func- 
tional derangements  of  the  general  system. 


164  MEDICAL  GYNECOLOGY. 

The  physical  signs  and  diagnoses  of  thoracic  diseases  and 
constitutional  affections  are  sufficiently  discussed  in  text- 
books and  lecture  courses,  hence  I  pass  over  them.  But  the 
physical  signs  of  the  abdomen  and  pelvis  require  special  con- 
sideration by  those  who  would  practice  gynecology,  and  a 
short  discussion  of  the  subject  is  fitting  here. 

The  abdomen  must  be  thoroughly  exposed,  the  patient 
resting  on  a  firm  bed  or  couch  with  the  shoulders  low  and  the 
lower  limbs  extended,  especially  if  free  fluid  is  suspected  in 
the  peritonaeum. 

Inspection  gives  the  general  appearance  of  the  abdomen 
as  to  shape,  thickness  of  wall,  oedema,  the  look  of  the  um- 
bilicus, a  swelling  at  any  part,  and  color. 

Palpation  should  be  gently  made  with  warm  hands 
which  move  steadily  and  evenly.  Rough  manipulation  may 
cause  peritonitis,  even  without  rupture  of  something  within 
the  abdomen.  Palpation  discovers  consistence,  solidity, 
fluidity,  regularity  or  irregularity,  immobility  or  degree  of 
mobility,  or  degree  of  sensitiveness  of  any  swelling  or  growth. 
Much  information  is  gleaned  from  a  bimanual  examination. 

Percussion^  both  superficial  and  deep,  usually  reveals  the 
same  state  of  affairs  as  careful  palpation,  but  is  a  more  cer- 
tain means  of  observing  the  solidity  of  a  tumor  and  whether 
there  is  present  fluid,  air,  or  both. 

Auscultation  of  the  abdomen  is  not  of  much  importance 
except  when  resorted  to  to  determine,  for  instance,  whether  a 
tumor  is  pregnancy  or  an  aneurism. 

Mensuration  tells  the  difference  in  size  in  the  two  lateral 
halves  of  the  body,  and  in  measuring  the  tape  should  be 
placed  in  the  median  line  of  the  back  and  brought  evenly 
around  to  a  point  directly  opposite  anteriorly.  When  the 
other  side  is  measured,  great  care  must  be  taken  that  the 
second  measuring  is  done  at  the  same  time  of  breathing  as 
the  first. 

For  convenience  of  description  of  its  contents,  the  abdo- 
men is  divided  into  nine  spaces  by  two  horizontal  and  two 
vertical  lines. 


METHODS  OF  EXAMINING  PATIENTS. 


165 


The  upper  transverse  line  crosses  the  abdomen  at  a  level 
with  the  most  prominent  part  of  the  ninth  costal  cartilages, 
while  the  lower  line  joins  the  crests  of  the  ilia,  as  seen  from 
the  front.      The  vertical  lines 
are    drawn   upward   from    the 
middle  of  Poupart's  ligaments. 

The  spaces  thus  mapped  out 
are  the  right  and  left  hypo- 
chondriac with  the  epigastric 
between  them ;  below  are  the 
right  and  left  lumbar  with  the 
umbilical  between  them ;  and 
the  inferior  spaces  are  the  right 
and  left  iliac  with  the  hypogas- 
tric between  them. 

The  rigM  hypocliondriac 
region  contains  a  large  part  of 
the  liver,  the  gall  bladder,  part 
of  the  right  kidney,  and  a  small 
part  of  the  colon  where  the  as- 
cending and  transverse  portions 
join. 

Percussion  and  palpation  are 
the  means  of  mapping  out  the 
liver  in  this  region. 

The  gall  bladder,  normally,  can  not  be  felt;  but  it  is 
located  with  its  fundus  below  the  ninth  right  costal  cartilage, 
and  the  line  of  its  distention  is  from  the  situation  of  its 
fundus  to  the  umbilicus. 

Pressed  between  the  two  hands,  one  in  front  and  the  other 
at  the  back,  the  gall  bladder  will  be  tense  if  filled  with  fluid, 
and  very  irregular  if  filled  with  calculi. 

Percussion  for  gall-bladder  diseases  is  well-nigh  useless. 

The  epigastric  region  contains  part  of  the  liver,  part  of 
the  stomach  and  both  its  orifices,  part  of  the  duodenum,  the 
pancreas,  the  coeliac  axis,  and,  possibly,  a  small  part  of  both 
kidneys. 


Fig.  12.— 1,  3,  right  and  left  hypo- 
chondriac; 2,  hypogastric;  4,  6, 
right  and  left  lumbar;  5,  umbili- 
cal; 7,  right  iliac;  8,  epigastric; 
9,  left  iliac  regions. 


166  MEDICAL  GYNECOLOGY. 

The  liver's  position  is  variable,  depending  upon  the  con- 
dition of  the  stomach.  It  is  to  be  recollected  that  the  liver  is 
enlarged,  and  therefore  its  area  of  percussion  dullness  in- 
creased, in  fatty  and  waxy  degeneration,  in  the  first  stage  of 
cirrhosis,  in  congestion,  in  tuberculosis,  cancer,  abscess,  and 
hydatids.  In  one  of  these — waxy  Imer — a  sharp,  firm  edge 
is  made  out  on  palpation. 

Local  enlargements  may  be  due  to  cancer,  syphilis,  or  ab- 
scess and  hydatids. 

Palpation  and  percussion  reveal  an  irregular  margin,  and 
at  times  nodules  can  be  felt. 

Gummata  or  syphiloma  of  the  liver  are  sometimes  tumors 
in  the  center  of  which  there  is  a  depression  which  can  be  felt. 

The  stomacTi's  position  here  is  most  variable  ;  indeed,  this 
organ  is  usually  in  the  region  immediately  below.  Palpation 
reveals  a  hard,  solid,  movable  tumor  in  most  cases  of  malig- 
nant gastric  disease.  Percussion  affords  data  regarding  dis- 
tention. 

Sometimes  foreign  bodies  are  swallowed  and  they  may  be 
mapped  out  through  the  abdominal  walls. 

Pancreatic  tumors,  cysts  or  not,  may  be  revealed  on 
careful  palpation  in  any  one  of  the  regions  in  the  upper  layer, 
so  variable  is  their  direction  of  growth. 

At  times  aortic  pulsation  can  be  felt  through  a  pancreatic 
tumor. 

Percussion  for  pancreatic  growths  is  unreliable.  A  pulsat- 
ing tumor,  expansile  in  character  and  revealing  on  ausculta- 
tion a  well-marked  hruit,  tells  of  an  aneurism  probably  of,  or 
about,  the  coeliac  axis. 

In  the  left  fiypochondriac  region  are  the  spleen,  fundus 
of  the  stomach,  part  of  the  left  kidney  and  its  capsule,  tail  of 
the  pancreas,  small  part  of  the  liver,  and  the  splenic  flexure 
of  the  colon. 

Palpation  can  not  reveal  a  normal  spleen,  but  percussion 
from  behind  shows  it  lying  between  the  ninth  and  eleventh 
ribs. 

Accumulations  of  fluid  in  the  pleural  cavity  may  push 


METHODS  OF  EXAMINING  PATIENTS.  16Y 

down  tlie  spleen,  and  the  organ  may  be  enlarged  in  lencocy- 
thgemia,  lymphadenoma,  malaria  (ague  cake),  waxy  degenera- 
tion, cancer,  cysts,  splenitis,  and  simple  hypertrophy. 
Notches  can  be  felt  on  an  enlarged  spleen,  and  on  percussion 
the  area  of  dullness  will  be  found  increased  in  proportion 
to  the  size  of  the  tumor.     It  is  greatest  of  all  in  malaria. 

I  have  known  the  spleen  in  malaria  to  double  its  size  in 
forty-eight  hours  from  the  onset  of  the  paroxysm.  A  very 
good  diagnostitian  in  general  medicine  sent  me  a  case  of  en- 
larged and  dislocated  spleen  which  he  diagnosed  as  an  ovarian 
or  fibroid  tumor.  I  have  seen  another  case  where  the  spleen 
was  impacted  in  the  pelvis,  and  was  taken  to  be  a  uterine 
fibroid.  A  dislocated  spleen  has  been  mistaken  for  a  wander- 
ing kidney. 

The  right  lumtar  region  contains  the  lower  part  of  the 
kidney,  part  of  the  ascending  colon,  and  some  coils  of  small 
intestine.  The  kidney  is  very  mobile  and  often  sinks  down 
on  the  slightest  enlargement. 

The  kidney  can  be  felt,  unless  fat  prevents,  by  putting 
one  hand  flat  on  the  abdomen  outside  of  the  rectus  muscle 
and  the  other  behind,  outside  the  erector-spinse  muscle,  be- 
low the  margin  of  the  ribs,  when  the  patient  takes  a  deep 
inspiration. 

Enlarged  kidney  may  be  due  to  fatty  or  waxy  degenera- 
tion, first  stage  of  Bright's  disease,  in  hydronephrosis  and 
pyonephrosis,  congestion,  and  at  times  in  renal  calculi.  Can- 
cer, abscess,  hydatids,  and  perinephritic  abscess  wiU  also 
cause  it.  The  line  of  kidney  enlargement  is  down  and  toward 
the  front.  A  small  enlargement  can  be  distinguished  from  a 
large  gall  bladder  by  being  posterior. 

As  the  size  increases,  the  kidney  comes  from  underneath 
the  ribs,  the  colon  over  it,  and  percussion  elicits  a  clear  note, 
unless  this  piece  of  bowel  be  collapsed,  in  which  case  a  thick 
band  may  be  felt  on  careful  palpation. 

In  the  urribilical  region  lie  the  omentum,  most  of  the 
small  intestine,  the  colon,  aorta,  and  possibly  a  small  part  of 
the  right  kidney. 


168  MEDICAL  aYNECOLOGY. 

The  omentum  may  be  felt  as  an  irregular  mass  from  in- 
flammation, tuberculosis,  cysts,  hydatids,  or  cancer.  Percus- 
sion reveals  dullness  in  those  diseases,  and  there  is  fixation 
also. 

Fsecal  accumulations  in  the  colon,  or  cancer,  may  induce 
a  tumor  along  the  line  of  the  colon. 

Palpation  and  percussion  afford  proof  of  the  existence  of 
a  tumor  of  the  small  intestine,  but  never  any  hint  of  its 
nature. 

An  aortic  aneurism  would  present  typical  expansile  pulsa- 
tion on  palpation ;  and  upon  auscultation  the  diagnostic  hruit 
would  be  found. 

In  the  left  lumbar  region  are  the  descending  colon  and 
some  of  the  small  intestine.  A  left  kidney  can  not  be  pal- 
pated, normally,  as  the  one  on  the  right  side  ;  but  when  it 
enlarges,  all  that  has  been  said  concerning  the  right  kidney 
holds  true. 

The  si)lenic  flexure  of  the  colon  is  sometimes  the  seat  of 
cancer,  and  its  tumor  may  be  mistaken  for  that  of  an  enlarged 
spleen. 

In  the  rigM  iliac  region  are  the  caecum,  with  the  appen- 
dix and  part  of  the  ascending  colon.  In  this  region  may 
appear  cancer  of  the  csecum,  or  distended  appendix,  from 
inflammation,  with  all  the  sequelae  of  appendicitis  and  masses 
of  impacted  faeces. 

A  dilated  appendix  has  a  variable  position,  being  some- 
times, also,  in  the  right  lumbar  or  umbilical  region.  Its 
shape  and  size  are  like  those  of  the  forefinger ;  it  is  very  sen- 
sitive, McBurney's  point  being  the  most  sensitive  spot ;  it 
is  midway  between  the  umbilicus  and  the  anterior  superior 
spine  of  the  ilium — i.  e.,  where  the  appendix  Joins  the  caecum. 
When  an  abscess  has  resulted  from  ajipendicitis,  a  tumor  of 
indefinite  outline  forms,  having  a  resistant  feel ;  and  a  vagi- 
nal or  rectal  examination  may  reach  the  swelling  from  below. 

Faecal  impaction  or  malignant  disease  cause  hard,  rough, 
slightly  movable  tumors,  the  former  sometimes  pitting  on 
pressure. 


METHODS  OP   EXAMINING   PATIENTS.  169 

The  hypogastric  region  contains  a  part  of  the  small  in- 
testine, the  bladder  when  distended,  the  uterus  when  en- 
larged, the  ovaries  if  growths  occur  in  them,  and  the  Fallo- 
pian tubes  when  a  foetus  or  fluid  greatly  distends  them. 

A  distended  bladder  rises  above  the  pubes  as  a  globular, 
fluctuating  tumor,  thin  walled,  tense,  and  slightly  movable. 

A  central  ovarian  tumor  may  at  times  appear  in  this 
fashion,  but  on  passing  the  catheter  the  case  will  be  decided. 

One  must  be  sure  that  the  catheter  enters  the  bladder. 

Uterine  enlargements  are  central,  soft,  or  solid,  continu- 
ous with  the  cervix  on  a  bimanual  examination.  Ovarian 
tumors  are  seldom,  if  ever,  in  the  median  line,  and  a  biman- 
ual examination  shows  them  disconnected  with  the  uterus. 
The  same  can  be  said  of  Fallopian  tumors,  save  that  there  is  a 
connection  between  them  and  one  side  of  the  uterus. 

The  left  iliac  region  contains  the  sigmoid  flexure  of  the 
colon,  part  of  the  descending  colon,  and  some  coils  of  small 
intestine.  The  flexure  may  be  the  subject  of  faecal  and  can- 
cerous tumors  and  fibroid  thickenings.  Intussusception  shows 
itself  as  an  elongated,  sausage-shaped  tumor,  tender  on  pres- 
sure, and  usually  on  the  left  side. 

This  ends,  properly  speaking,  the  discussion  of  tumors 
located  distinctly  in  one  of  these  nine  regions ;  and  there  now 
remain  to  be  considered  those  cases  where  the  whole  cavity 
is  nearly  or  completely  filled  with  a  cystic  or  a  solid  growth. 
Cystic  tumors  are  usually  renal  or  ovarian,  but  the  natural 
uterine  enlargement,  hydramnios,  and  encysted  ascitic  fluid 
must  always  be  kept  in  mind  as  possible  occurrences.  Cysts 
in  the  upper  part  of  the  abdomen  raise  the  chest  wall  and 
move  down  on  a  deep  inspiration.  In  all  large  fluid  collec- 
tions in  the  abdomen  fluctuation  occurs ;  and  impulse  given 
by  the  hand  on  one  side  of  the  abdomen  is  transmitted  to  the 
hand  placed  on  the  other  side. 

A  tumor  in  the  upper  part  of  the  abdomen  gives  a  dull 
note  above  the  growth,  for  there  is  no  intestine  between  the 
wall  and  the  tumor. 

Renal  cysts  bulge  more  in  one  line  than  the  other,  and  the 


170  MEDICAL  GYNECOLOGY. 

colon  runs  down  on  tlie  inner  side  of  the  swelling.  Deep 
inspiration  makes  the  percussion  note  tympanitic  over  such  a 
tumor,  where  formerly  it  has  been  dull. 

In  tumors  with  no  pelvic  connection  a  clear  note  runs 
across  the  abdomen  below  the  cyst ;  when  the  growth  springs 
from  the  pelvis  the  reverse  is  the  case. 

Ascitic  fluid  is  differentiated  from  a  cyst  by  the  great 
difficulty  in  respiration  in  comparison  to  the  size  of  the 
swelling  and  by  the  percussion  note. 

Solid  tumors  of  the  abdomen  do  not  differ,  except  in 
their  feeling  of  consistence,  from  cystic  growths.  Their  posi- 
tion may  be  the  same,  they  may  grow  to  as  great  a  size,  and 
they  may  resemble  a  cystic  tumor  except  in  the  absence  of 
fluctuation. 

Whenever  an  abdominal  tumor  could  possibly  be  a  preg- 
nancy, auscultation  must  be  most  carefully  made.  Even 
in  very  large  cystic  tumors  this  may  be  necessary,  from  the 
possibility  of  an  abnormally  large  amount  of  amniotic  fluid, 
or  from  the  presence  of  a  cystic  growth  in  addition  to  the 
pregnancy. 

Yery  rarely  the  abdomen  may  be  distended  by  a  mass  of 
faecal  matter,  the  collection  being  generally  distributed  over 
the  whole  abdomen.  This  condition  may  present  the  appear- 
ance of  a  distinct  abdominal  tumor,  and  it  is  diagnosticated 
either  by  the  pitting  of  the  mass  on  pressure  or  by  careful 
percussion,  when  it  will  be  found  that  the  note,  if  not  abso- 
lutely tympanitic  in  the  center  of  the  abdomen,  is  decidedly 
less  dull.  Rectal  examination  may  give  no  information,  as 
the  bowel  may  be  either  loaded  or  empty.  A  knowledge  of 
how  to  examine  the  abdomen  and  pelvis  is  equally  necessary 
to  the  physician  and  surgeon,  in  order  that  the  diagnosis  of 
medical  and  surgical  diseases  may  be  made  and  differentiated. 
Instrumental  examinations  belong  to  the  province  of  the  sur- 
geon, and  will  not  be  discussed  in  this  work. 


CHAPTER  Xy. 

DERANGEMEISTTS   OF   MENSTEUATION   DUE  TO   CERTAIN 
*  AFFECTIOlSrS   OF   THE  NUTRITIVE   SYSTEM. 

The  sexual  functions  are  liable  to  derangement  in  all  acute 
and  chronic  diseases  of  the  general  system.  The  essential 
fevers  and  inflammatory  affections,  such  as  pneumonia,  very 
frequently  give  rise  to  amenorrhoea  either  during  the  acute 
stage  of  the  disease  or  in  the  period  of  convalescence.  It  is 
not  an  uncommon  occurrence  for  menstruation  to  be  delayed 
in  case  the  menstrual  period  arrives  in  the  early  stages  of  the 
acute  diseases  ;  but  in  those  cases  where  the  menstrual  func- 
tion is  normally  performed  during  the  acute  stages  the  men- 
struation may  be  delayed  during  the  period  of  convalescence. 
In  exceptional  cases  menorrhagia  occurs.  I  have  not  infre- 
quently seen  menorrhagia  in  eruptive  diseases  occurring  in 
adults.  In  one  case  of  the  malignant  type  of  measles  in  a 
young  girl  who  had  only  menstruated  two  or  three  times  be- 
fore the  eruptive  disease,  menstruation  came  on  about  the 
fourth  day  after  the  appearance  of  the  eruption  and  was  ex- 
ceedingly profuse.  The  disease  was  of  the  hsemorrhagic  type 
and  the  menstrual  flow  was  extraordinary,  no  doubt  due  to 
the  hsemorrhagic  condition.  The  case  ended  fatally.  I  have 
seen  menorrhagia  in  remittent,  and  occasionally  in  intermit- 
tent, fever  which  was  no  doubt  caused  by  the  malarial  poison, 
as  it  entirely  disappeared  after  recovery. 

Causation. — Amenorrhoea  in  acute  diseases,  either  in  the 
early  stages  or  during  convalescence,  is  undoubtedly  due  to 
malnutrition.  Menorrhagia  is  in  certain  cases  due  to  the  de- 
teriorated condition  of  the  blood  which  establishes  a  hsemor- 

12  171 


172  MEDICAL   GYXECOLOGY. 

rhagic  condition.  In  the  malarial  fevers  I  believe  menor- 
rhagia  is  produced  by  the  general  liypersemia  of  the  abdomi- 
nal and  pelvic  viscera  and  the  obstructed  return  circulation 
caused  by  the  enlargement  of  the  liver  and  spleen. 

Treatment. — In  the  management  of  those  cases  the  whole 
attention  should  be  given  to  the  constitutional  disease.  The 
indications  clearly  are  to  restore  the  conditions  of  the  general 
system  which  are  necessary  to  normal  menstruation,  and 
when  these  are  restored — in  other  words,  after  recovery — the 
amenorrhoea  will  be  entirely  corrected  without  the  aid  of  any 
special  treatment  directed  to  the  pelvic  organs.  The  same 
indications  are  present  in  cases  of  menorrhagia  due  to  the 
diseases  already  referred  to.  Whatever  gives  relief  to  the 
constitutional  disturbance  will  accomplish  all  that  is  requisite. 
In  case  the  menorrhagia  should  in  itself  become  a  serious 
condition,  efforts  should  be  made  to  arrest  it.  For  this  pur- 
pose I  have  found  aromatic  sulphuric  acid,  combined  with 
digitalis  in  case  the  heart  is  acting  feebly,  to  answer  excel- 
lently. Should  the  stornach  not  tolerate  these  remedies,  the 
fluid  extract  of  hydrastis  canadensis  in  full  doses  should  be 
given  per  rectum.  If  these  should  fail,  they  may  be  re- 
enforced  by  warm,  astringent,  vaginal  douches.  I  have  found 
one  quart  of  warm  water  \vith  half  an  ounce  of  vinegar  most 
efficient.  In  obstinate  cases  the  vaginal  tampon  may  be 
resorted  to. 

DERANGEMENT   OF  THE   MENSTRUAL  FUNCTION  FROM 
CHRONIC   MALNUTRITION. 

There  are  certain  diathetic  conditions  which  frequently 
impair  the  menstrual  function.  Chief  among  these  are  scrof- 
ula, tuberculosis,  and — closely  allied  to  these  in  its  effects — 
syphilis.  Next  in  order  come  toxic  conditions  like  lead  and 
tobacco  poisoning,  malaria,  and  foul  air.  Scrofulous  women, 
who  not  infrequently  are  phlegmatic  in  temperament  (the 
apathiques)  and  inclined  to  obesity,  are  often  anaemic,  and 
suffer  from  amenorrhoea  or  scanty  menstruation.  Another 
combination,  as  it  may  be  termed,  of  morbid  conditions  is 


DERANGEMENTS  OF  MENSTRUATION.  173 

seen  in  tTie  scrofulous  and  cUorotic  women.  They  are  espe- 
cially prone  to  amenorrhoea  or  scanty  and  imperfect  menstru- 
ation. They  usually  menstruate  rather  sparingly  in  their  best 
condition,  and  when,  from  any  intercurrent  causes,  they  be- 
come more  anaemic  than  usual,  menstruation  is  after  a  time 
likely  to  be  suppressed,  or  to  become  so  exceedingly  scanty 
that  it  is  hardly  worthy  of  the  name.  In  regard  to  tuberculo- 
sis, it  is  well  understood,  of  course,  that  amenorrhcsa  occurs 
in  the  advanced  stages  of  pulmonary  tuberculosis,  for  exam- 
ple, but  i^  frequently  happens  that  in  what  used  to  be  called 
the  pretubercular  stage  amenorrhoea  occurs  in  those  of  the 
tubercular  tendency  or  diathesis.  Exceptional  cases  are  seen 
where  the  sexual  organs  are  well  developed  and  functionally 
active  in  those  of  this  diathesis,  and  in  whom  there  is  menor- 
rhagia.  In  syphilis,  in  the  secondary  stage,  when  there  is 
marked  ansemia  with  impaired  assimilation  and  disintegra- 
tion, menstruation  is  often  entirely  suppressed,  or  is  scanty 
and  of  short  duration.  On  the  other  hand,  cases  are  not  in- 
frequently seen  in  which  there  is  menorrhagia  ;  but  I  am  sat- 
isfied that  here  there  are  syphilitic  lesions  of  the  endome- 
trium which  account  for  the  profuse  menstruation,  and  that 
it  is  not  wholly  due  to  the  general  malnutrition. 

In  regard  to  cases  of  toxaemia,  the  influence  on  the  men- 
strual function  appears  to  be  due  to  ansemia,  produced  by 
these  toxic  agents  rather  than  by  any  direct  influence  of  the 
materies  morbi  on  the  sexual  system. 

Causation. — In  all  of  the  affections  named,  the  derange- 
ment of  menstruation  is  evidently  due  to  the  imperfect  quan- 
tity or  quality  of  blood  supply,  the  menstrual  flow  being  sup- 
pressed or  curtailed  by  the  meager  quantity  or  imperfect 
quality  of  the  blood. 

The  treatment  of  such  cases  should  be  directed  to  over- 
coming as  far  as  possible  the  constitutional  affections.  The 
treatment  of  scrofulous  and  tuberculous  subjects  suffering 
from  amenorrhoea  does  not  entirely  come  within  the  scope  of 
the  present  work ;  but  I  may  say  that  I  have  succeeded  in 
overcoming  the  anaemia  and  in  improving  assimilation  and 


17J:  :\[EDICAL  GYNECOLOGY. 

disintegration  in  scrofulous  and  syphilitic  subjects  by  the 
prolonged  use  of  small  doses  of  bichloride  of  mercury  with 
bichloride  of  iron,  giving  due  attention  to  any  derangements 
of  the  digestive  organs  which  from  time  to  time  may  appear. 
While  all  will  grant  that  the  mercury  and  iron  are  indicated 
in  syphilitic  subjects,  some  may  doubt  their  efficacy  in  tuber- 
culous affections,  but  I  am  satisfied  that  I  have  seen  as  good 
results  in  those  of  the  strumous  or  scrofulous  diathesis.  To 
some  extent  this  applies  to  the  tubercular  cases ;  but  in  many 
of  those,  especially  such  as  are  of  spare  habit,  I  have  found 
that  the  use  of  wine,  cream,  and  cod- liver  oil,  with  small  doses 
of  iodine,  answers  better.  In  order  to  obtain  the  iodine  and 
wine  in  acceptable  form,  I  have  of  late  years  been  using  the 
Yin  IS'ourry  lodotane  (J.  Nourry,  of  Havre,  France). 

In  the  second  class  of  cases  described,  due  to  some  tox- 
semia,  I  may  mention,  first,  chronic  malarial  poisoning,  which 
is  so  prevalent  in  this  country.  After  the  periodic  fever  has 
been  relieved  and  there  yet  remains  some  enlargement  of  the 
liver  and  spleen,  with  more  or  less  hypersemia  of  the  pelvic 
and  abdominal  viscera,  and  anaemia,  I  find  that  a  similar 
course  of  treatment  is  indicated  whether  the  patient  suffers 
from  amenorrhoea  or  from  menorrhagia.  It  is  necessary  dur- 
ing the  menstrual  period  to  keep  the  patient  quiet  in  the 
recumbent  position  and  to  employ  aromatic  sulphuric  acid 
and  hydrastis  canadensis  to  limit  the  fiow  in  the  menorrhagic 
cases.  In  the  intermenstrual  periods  I  find  that  occasional 
doses  of  calomel  correct  gastric  hypersemia  or  impaired  secre- 
tion, at  the  same  time  giving  some  saline  or  mineral  water  to 
keep  the  bowels  regular,  with  iron  and  arsenic  in  small  doses 
administered  for  a  long  period  of  time.  The  chloride  of  iron 
and  chloride  of  arsenic,  well  diluted,  can  be  combined  and 
given  after  meals  vdth  marked  effect.  My  habit  is  to  keep 
the  patient  on  this  preparation  for  one  week,  and  to  give,  the 
week  following,  about  five  drops  of  the  tincture  of  iodine  in  a 
solution  of  sirup  and  water,  with  two  or  three  drops  of  Fowl- 
er's solution,  after  each  meal.  This,  with  pure  out-of-door 
air,  good  food,  and  a  requisite  amount  of  rest  conjoined  with 


DERANGEMENTS  OF   MENSTRUATION.  175 

a  reasonable  amount  of  exercise,  will  soon  establish  the  men- 
strual function  in  its  normal  condition. 

With  regard  to  lead  poisoning,  I  have  seen  only  a  few  cases 
among  girls  who  worked  in  lead,  such  as  type  founders  and 
typesetters.  The  ordinary  treatment  is  here  indicated  ;  but 
after  the  evidences  of  the  lead  poisoning  have  disappeared,  the 
patient  generally  requires  a  course  of  chalybeate  tonics  in 
order  to  restore  the  deranged  menstrual  function.  Among  a 
few  hospital  patients — sewing  girls  who  spent  their  days  in 
overheated,  ill- ventilated,  crowded  rooms — I  have  only  found 
it  necessary  to  get  them  into  the  open  air,  to  keep  the  bowels 
regular,  to  get  the  skin  acting  through  the  agency  of  bathing 
and  friction,  and  then  to  resort  to  general  tonic  treatment. 

In  nicotine  poisoning  there  is  amenorrhoea  invariably.  I 
have  seen  a  number  of  cases  in  hospital  practice  among  girls 
who  worked  in  tobacco  factories.  Change  from  their  occupa- 
tion, or  removing  the  cause  and  building  up  by  restoratives  is 
sufficient  and  effectual  treatment. 

DERANGEMENTS  OP  MENSTRUATION  OATJSED  BY  IMPAIRED 
DIGESTION,  ASSIMILATION,  AND   IMPERFECT  ELIMINATION. 

Amenorrhoea,  or  scanty  menstruation,  is  so  often  seen 
among  those  who  are  suffering  from  derangement  of  the  di- 
gestive organs  and  consequent  malnutrition,  that  I  have 
arranged  the  subjects  of  it  in  two  classes — namely,  those  suf- 
fering from  some  gastric  derangement  which  impairs  the 
appetite  and  is  usually  attended  by  slow  and  laborious  di- 
gestion and  constipation,  and  those  suffering  from  impaired 
or  sluggish  disintegration  and  elimination,  a  condition  which 
has  been,  I  think,  appropriately  called  excrementitious  pleth- 
ora or  faulty  elimination.  I  believe  this  to  be  akin  to  what 
is  now  called  lithsemia.  Of  the  first  class  it  is  understood 
that  there  is  no  organic  disease  of  the  stomach,  such  as  gas- 
tric ulcer  or  some  of  the  more  important  degenerative  dis- 
eases, but  a  temporary  impairment  of  the  function  of  the 
organ  from  overwork — mental,  physical,  or  both — or  lack  of 
sufficient  mental  or  physical  exercise  to  maintain  health.     On 


176  MEDICAL  GYNECOLOGY. 

the  other  hand,  poor  food  supply,  in  quantity  or  quality,  is 
frequently  the  cause  of  the  gastric  derangement  and  loss  of 
appetite.  Strange  as  it  may  appear,  it  is  nevertheless  true, 
that  the  very  poor  suffer  from  bad  food  supply — insufficient 
in  quantity,  poor  in  quality,  and  ill  prepared ;  while,  on  the 
other  hand,  those  who  are  abundantly  able  to  live  well  ruin 
their  digestion  by  overindulgence  in  improper  articles  of  food, 
especially  highly  seasoned  dishes,  and  sugar  in  all  the  tempt- 
ing forms  in  which  it  is  offered  at  the  present  time.  With  the 
class  where  the  appetite  is  good  or  fair,  the  food  supply  suffi- 
cient, and  the  quantity  of  food  taken  generally  superabun- 
dant and  hence  ill  digested,  and  where  the  habits  of  life  are 
sedentary  either  from  choice  or  necessity,  elimination  is  very 
imperfect.  The  history  of  the  first  class  may  be  briefly  given 
as  that  of  patients  suffering  from  impaired  strength,  who  are 
easily  exhausted.  The  pulse,  color  of  the  skin,  and  mucous 
membrane  show  more  or  less  anaemia  ;  the  tongue  is  coated  ; 
the  bowels  are  constipated  ;  the  appetite  is  poor ;  there  is 
general  drowsiness  after  eating,  and  often  distress  in  the 
gastric  region  ;  the  skin  is  dry  ;  and  there  is  lack  of  mental 
energy,  or,  in  case  there  is  any  considerable  mental  activity, 
the  mind  is  easily  fatigued,  and  mental  depression  is  liable  to 
follow.  Menstruation  is  usually  scanty  and  of  short  dura- 
tion, and  in  long-continued  cases  there  may  be  entire  sup- 
pression. 

The  diagnosis  is  made  by  the  exclusion  of  all  organic, 
renal,  or  hepatic  disease  after  careful  examination. 

Most  of  the  causes  have  been  mentioned  already.  They 
are  improper  food,  overtaxation,  confinement  indoors,  or  the 
opposite  of  this,  overindulgence  in  too  rich  food,  and  a  lack 
of  wholesome  and  necessary  mental  and  physical  occupation. 

In  the  treatment  the  first  object  is  to  improve  the  general 
secretions  of  the  alimentary  canal.  This,  I  find,  can  be  done 
best  by  small  doses  of  calomel  well  diluted,  given  every  hour 
for  a  day  and  followed  by  a  saline  laxative  or  cathartic  on 
the  following  morning ;  then  to  keep  the  bowels  regular,  a 
pill  composed  of  quinine,  belladonna,  and  compound  extract 


DERANGEMENTS  OP  MENSTRUATION.  I77 

of  colocyntli.  To  stimulate  tlie  appetite  I  prefer  to  give  very- 
small  doses  of  the  bitter  tonics — half  a  drachm  of  tincture  of 
columbo  or  of  gentian  well  diluted,  or  a  larger  dose  of  the 
infusion  of  either.  When  this  fails  to  give  the  desired  result, 
I  resort  to  three  or  four  drops  of  nux  vomica  with  two  drops 
of  wine  of  ipecac  in  half  a  wineglassful  of  water.  The  food 
should  be  plain  and  tempting.  I  am  in  the  habit  of  allowing 
the  patients  to  choose  their  own  food,  knowing  that  if  it  is 
agreeable  they  will  take  more  of  it  and  digest  it  better. 
Should  tliey  choose  some  unwholesome  or  absurd  article, 
which  selection  I  know  comes  from  a  perverted  appetite,  I 
forbid  it.  In  order  to  aid  digestion  I  give  a  teaspoonful  each 
of  Forbes's  diastase  and  Fairchild's  essence  of  pepsin  with  a 
little  aromatic  or  peppermint  water  or  a  very  small  quantity 
of  cardamom.  Out-of-door  air,  exercise,  the  more  agreeable 
the  better,  sufficient  bathing  to  keep  the  skin  active — luke- 
warm sponge  bathing  with  friction  answering  in  most  cases — 
are  all  demanded.  Those  who  are  used  to  cold  bathing  I 
advise  to  continue  it.  Warm  bathing  I  have  seldom  found 
suitable  in  such  cases.  The  patient  is  kept  on  this  line  of 
treatment  until  the  appetite  and  digestion  are  good  and 
evidences  of  better  assimilation  are  seen.  Then  I  resort  to 
chalybeate  tonics,  preferring  the  pyrophosphate  of  iron,  three 
or  four  grains  after  meals,  or  the  tincture  of  chloride  of  iron. 
If  there  is  evidence  of  any  strumous  or  tubercular  taint,  I  em- 
ploy the  sirup  of  the  iodide  of  iron.  When  general  nutrition 
is  established  on  a  normal  basis,  I  find  that  the  menstrual 
function  is,  as  a  rule,  restored. 

In  the  management  of  the  second  class  of  cases,  in  which 
the  primary  trouble  is  excrementitious  plethora  or  lithsemia, 
I  first  endeavor  to  secure  a  normal  elimination  by  getting  the 
kidneys,  liver,  and  bowels  to  act  normally.  I  find  here  that 
mild  chloride  of  mercury  is  the  best  of  all  diuretics.  At  the 
same  time  it  generally  improves  the  secretions  along  the  ali- 
mentary canal,  including  the  hepatic.  I  generally  keep  such 
a  patient  for  a  couple  of  days  on  small  doses  of  calomel,  say 
one  tenth  of  a  grain  every  hour  during  the  day,  and  then 


178  MEDICAL  GYNECOLOGY. 

follow  it  with  a  saline  cathartic  unless  the  patient  suffers 
from  flatulence,  when  I  prefer  the  fluid  extract  of  cascara 
sagrada  with  tincture  of  belladonna.  After  this  I  endeavor 
to  keep  the  bowels  regular — that  is,  to  secure  a  free  evacua- 
tion daily  by  means  of  some  of  the  mineral  waters  taken 
warm  early  in  the  morning,  or,  if  they  are  not  suitable,  a 
sufficient  quantity  of  the  cascara  at  night.  The  kidneys 
must  be  made  to  act  by  having  the  patient  drink  freely  of 
distilled  water  or  a  spring  water  known  to  be  as  near  purity 
as  possible,  added  to  which  is  enough  bitartrate  of  potash  to 
give  it  an  agreeable,  acidulous  taste.  If  the  patient  is  rest- 
less and  given  to  dreaming,  with  pain  in  the  back  of  the  neck, 
queer  feelings  about  the  head,  and  wandering  pains  here  and 
there  in  the  body,  I  give  a  dose  of  bromide,  usually  twenty 
grains  in  the  afternoon  and  the  same  at  bedtime.  I  ask 
her  to  take  at  first  but  very  little  exercise,  substituting  for 
it  massage  once  a  day  and  giving  very  little  food,  and  that 
of  the  simplest  kind — oatmeal,  farina,  or  barley  gruel,  a  few 
raw  oysters,  a  little  milk  and  toast,  and  a  very  small  quan- 
tity of  beef,  mutton,  or  chicken,  with  occasionally  an  egg. 
Here,  again,  I  would  consult  the  wishes  of  the  patient  in  case 
her  inclination  does  not  lead  to  the  use  of  wholesome  articles 
of  diet.  The  great  object  should  be  to  give  only  food  enough 
to*  be  thoroughly  digested,  and  the  less  animal  food  the  better. 
In  fact,  I  have  found  that  many  of  those  cases  get  along 
without  any  animal  food  at  all,  although  they  had  been  in 
previous  years  great  eaters  of  meat.  I  prefer  to  keep  such 
patients  Just  a  little  hungry  all  the  time,  and  then  I  am  confi- 
dent that  they  will  thoroughly  digest  and  assimilate  what  they 
take,  and,  as  I  make  no  great  demands  upon  their  strength 
by  muscular  and  mental  activity,  and  see  that  elimination  is 
carried  on  as  perfectly  as  can  be,  I  usually  find  that  they 
begin  to  improve  rapidly.  Many  such  cases  are  inclined  to 
be  fleshy,  and  they  generally  begin  to  improve  as  soon  as 
they  show  evidences  of  losing  flesh.  The  flrst  class  that  I 
mentioned  are  weak  and  depressed,  the  depression  coming 
from  lack  of  nourishment,  their  tissues  being  poorly  nour- 


DERANGEMENTS  OF  MENSTRUATION.  179 

ished.     The  latter  class  owe  their  oppression  to  the  presence 
of  effete  material  that  must  be  eliminated. 

MENSTRUAL  DERANGEMENTS  FROM    DEFECTIVE 
INNERVATION. 

One  of  the  conditions  of  normal  menstruation,  and  in- 
deed for  the  natural  performance  of  all  the  functions  of  the 
sexual  organs,  is  proper  innervation.  It  follows,  as  a  matter 
of  course,  that  noticeable  disturbance  of  the  function  or  mal- 
nutrition of  the  nervous  system  will  derange  the  catamenia. 
Deranged  menstruation  (appearing  as  amenorrhoea,  scanty 
menstruation,  and  occasionally  menorrhagia)  arising  from 
deranged  innervation  is  usually  observed  in  one  of  two 
forms — the  first  appearing  abruptly  from  some  acute  disturb- 
ance of  the  brain  and  nervous  system,  and  the  other,  which 
may  be  called  subacute,  as  a  form  of  neurasthenia  or  mal- 
nutrition of  the  centers.  In  the  first  class  menstruation  is 
abruptly  suppressed  by  some  strong  impression  or  shock, 
fear,  surprise,  great  joy  or  sorrow.  Those  cases  of  suppressed 
menstruation  which  occur  from  a  sea  voyage  or  change  of 
residence  and  the  excitement  of  traveling  also  are  classed 
under  this  head.  The  history  is  usually  that  a  short  time 
before  the  menstrual  period  some  shock  from  fright,  acci- 
dent, or  profound  disturbance  of  the  emotions,  which  neces- 
sarily continues  for  a  time,  has  occurred,  and  menstruation 
fails  to  appear.  Indeed,  such  cases  are  usually  brought  to 
the  notice  of  the  physician  when  menstruation  does  not  come 
on  at  the  proper  time,  when  the  patient  is  usually  found  in 
an  excited,  nervous  condition.  The  menstrual  molimen  may 
be  most  marked,  the  patient  complaining  of  backache,  pelvic 
tenesmus,  cerebral  engorgement  —  as  evidenced  by  flushed 
face,  throbbing  temporal  arteries,  and  headache  of  the  con- 
gested variety — and  a  pulse  usually  accelerated  and  tense. 
These  are  associated,  as  a  rule,  with  derangement  of  the  di- 
gestive organs.  The  function  of  the  kidneys  is  often  dis- 
turbed, the  secretion  of  urine  being  sometimes  excessive,  at 
other  times  scant,  and  the  bladder  is  irritable.     In  excep- 


180  MEDICAL   GYNECOLOGY. 

tional  cases  menstruation  may  appear  before  the  proper  time, 
and  menorrhagia  may  occur. 

Causation. — It  has  often  been  demonstrated  experimen- 
tally that  digestion  is  arrested  by  a  strong,  sudden  mental 
imjDression,  especially  if  the  impression  maintains  a  high 
state  of  mental  tension  for  any  length  of  time.  It  seems  as 
if  the  nerve  forces  which  controlled  the  function  were,  for 
the  time  being,  inhibited.  No  doubt  this  is  the  case  with 
regard  to  the  function  of  the  uterus.  The  nerve  forces  are 
interrupted  in  their  influence  upon  the  function  of  men- 
struation. Menorrhagia,  when  it  occurs  in  connection  with 
this  mental  and  nervous  disturbance,  is  not  so  easily  ac- 
counted for.  It  may  be  that  the  vaso-motor  nerves  are  stimu- 
lated or  shocked  in  some  cases  so  that  the  vessels  they  con- 
trol are  contracted,  while  in  others  the  shock  may  be  severer, 
or  the  nerves  weaker,  the  result  being  that  complete  control 
of  the  caliber  is  lost  and  then  the  vessels  dilate  beyond  the 
normal.  In  those  cases  seen  in  my  own  practice  that  have 
had  menorrhagia  the  acute  mental  disturbance  came  at  the 
time  when  menstruation  was  due  or  had  already  begun,  but 
why  the  flow  is  profuse  is  not  quite  clearly  made  out. 

Treatment. — The  beneficial  effects  of  treatment  depend  to 
some  extent  upon  the  time  at  which  the  patient  is  seen.  If 
taken  under  care  immediately  after  the  mental  disturbance 
appears  (whatever  it  may  be),  and  she  can  be  quieted  and 
relieved,  the  response  to  remedies  is  often  quite  satisfactory 
and  menstruation  may  come  on  in  due  time.  If  the  trouble 
that  has  been  set  up  has  been  prolonged,  the  treatment  is  not 
always  so  satisfactory.  IS"©  matter  what  the  disturbance  has 
been,  whether  shock  from  fear  or  sorrow,  the  patient  is  gen- 
erally found  in  a  state  of  high  mental  excitement,  and  the 
great  object  is  to  produce  rest  and  quiet.  Unless  the  patient 
is  a  feeble  subject,  the  bromides  are  of  the  greatest  possible 
value,  and  they  should  be  given  in  sutficient  doses  to  produce 
sleep  and  that  peculiar  indifference  which  follows  full  doses 
of  bromides.  At  the  same  time  every  effort  should  be  made 
to  quiet  the  cerebral  circulation  by  stimulating  food,  bathing. 


DERANGEMENTS  OP  MENSTRUATION.  181 

friction  of  the  skin,  or  artificial  heat  to  the  extremities.  When 
once  the  patient  has  been  calmed  and  has  obtained  sleep,  and 
any  apprehensions  that  may  have  prevailed  have  subsided, 
then  rest  and  protection  from  further  disturbance  should  be 
enjoined,  and  the  bromides  repeated  if  there  is  a  disposition 
to  recurrence  of  the  original  symptoms.  In  cases  of  pro- 
found sorrow  it  is  often  necessary  to  combine  with  the  bro- 
mides, or  follow  them  by,  diffusible  stimulants  like  ammonia 
and  camphor,  avoiding  opium,  if  possible,  and  yet  opium 
may  be  given  in  case  other  remedies  fail,  but  in  small  doses. 
If  the  mental  perturbation  persists,  the  patient's  time  should 
be  occupied  in  the  use  of  baths,  massage,  central  galvaniza- 
tion, frequent  meals  of  light  food,  and  attention  to  the  bowels, 
which  are  to  be  kept  in  a  lax  condition.  Very  much  can  be 
accomplished  in  such  cases  by  a  judicious,  cheerful  nurse, 
who  can  distract  the  patient's  attention.  When  the  time  for 
the  recurrence  of  menstruation  arrives  I  have  found  that  the 
diffusible  stimulants  like  camphor  with  ammonia,  and  in 
some  what  feeble,  depleted  subjects,  cannabis  Indica  and  am- 
monia with  chloric  ether,  help  to  bring  on  the  flow.  If  that 
period  passes,  then  attention  to  the  general  health  should  be 
continued  until  the  next  period,  when  the  diffusible  stimu- 
lants should  be  again  employed  ;  and  if  these  fail,  the  faradic 
current  should  be  passed  through  the  pelvis.  In  case  the 
menstrual  flow  comes  on,  but  attended,  as  it  frequently  is, 
with  unusual  pain  and  discomfort,  moderate  doses  of  bro- 
mide with  antipyrine  will  often  give  decided  relief.  There 
are  other  remedies  which  may  be  required  in  this  condition, 
but  I  shall  reserve  what  I  have  to  say  about  them  for  the 
chapter  on  Dysmenorrhoea. 

DERANGEMENTS   OF  THE   FUNCTIONS   OF  THE   SEXUAL 

ORGANS,    CHIEFLY  MENSTRUATION,   ARISING  FROM 

NERVOUS   EXHAUSTION   OR   NEURASTHENIA. 

The  subject  for  present  consideration  is  certain  states  of 
the  nervous  system  which  are  directly  the  cause  of  menstrual 
derangements.    This  nervous  exhaustion  or  neurasthenia,  and 


182  MEDICAL  GYNECOLOGY. 

its  ultimate  effects  on  the  generative  organs,  is  in  strong  con- 
trast with  the  sudden  or  acute  derangements  of  innervation 
which  have  just  been  discussed.  This  exhaustion  of  the  nerv- 
ous system  is  slowly  developed,  and  its  ultimate  results  ap- 
pear late  in  the  progress  of  the  disease.  It  is  most  frequently 
seen  among  young  women,  but  may  occur  at  any  time  of 
life.  It  is  known  by  a  variety  of  names,  such  as  nervous 
debility,  nervous  prostration,  and  nervous  exhaustion ;  but  I 
prefer  the  term  neurasthenia,  as  first  employed  by  Dr.  George 
M.  Beard,  as  it  appears  to  me  to  be  the  most  expressive  and 
comprehensive.  This  condition  of  the  nervous  system  is  no 
doubt  in  many  cases  brought  about  by  imperfect  nutrition 
and  in  others  by  overtaxation  of  the  nervous  system.  There 
are  two  forms  seen  in  practice,  in  one  of  which  there  is 
probably  anaemia  of  the  brain  and  spinal  cord,  while  in  the 
other  there  is  passive  hypersemia  or  congestion.  I  do  not 
know  that  the  difference  in  cerebral  circulation  accounts  for 
the  difference  in  the  clinical  history  of  the  two  classes,  and 
even  neurologists  are  not  agreed  upon  this  point.  I  am,  how- 
ever, satisfied  that  there  are  those  who  show  symptoms  of 
general  neurasthenia  associated  with  anaemia,  and  others  who 
differ  in  the  history  and  give  symptoms  which  suggest  a 
passive  hypersemia  of  the  brain  and  nervous  system  gener- 
ally. This  theory — whether  it  is  based  upon  fact  or  not — 
aids  in  understanding  and  treating  such  cases  as  come  under 
observation,  and  hence  I  accept  it. 

DERANGEMENTS   OP   MENSTRUATION   ARISING  FROM    MAL- 
NUTRITION  OP   THE    NERVOUS   SYSTEM. 

Amenorrhoea,  or  scanty  menstruation,  is  the  most  common 
deviation  from  the  normal  functional  action  of  the  uterus, 
but  menorrhagia  and  dysmenorrhoea  not  infrequently  occur 
from  the  same  causes.  Dysmenorrhoea  and  scanty  menstrua- 
tion occur  together  in  certain  cases.  Amenorrhoea  occurs  in 
those  who  suffer  from  cerebral  anaemia,  and  occasionally  it  is 
associated  with  unusual  pain.  Menorrhagia  is  far  more  likely 
to  occur  in  cerebral  congestion  of  the  asthenic  type,  and  here. 


DERANGEMENTS  OP  MENSTRUATION.  183 

if  the  flow  is  normal,  there  is  general  dysmenorrhoea.  Pain- 
ful menstruation  is  of  the  neuralgic  type  and  characterized 
by  irregularity  in  the  time  of  its  occurrence  in  relation  to  the 
flow.  Occasionally  a  period  passes  without  pain  or  with  very 
little,  while  the  next  may  be  attended  with  great  suffering. 
Relief  from  pain  in  such  patients  often  results  from  change 
of  climate  or  agreeable  occupation  at  the  time  of  the  flow. 
Leucorrhoea  appears  in  the  progress  of  the  trouble,  with  back- 
ache and  slight  pelvic  tenesmus,  and  occasionally  pain  during 
the  menstrual  period.  This  aggravates  the  whole,  increasing 
the  neurasthenia  and  also  the  dysmenorrhoea.  If  amenor- 
rhoea  continues,  there  is  usually  menstrual  molimen,  often 
aggravated  in  aJl  its  characteristics. 

Absence  of  menstruation  is  no  doubt  itself  very  often  a 
conservative  event,  especially  if  there  be  ansemia  and  general 
malnutrition  ;  and  the  nervous  affection  may  be  to  a  certain 
extent  relieved  by  the  stoppage  of  this  function.  If,  how- 
ever, the  amenorrhoea  is  long  continued,  the  general  health  of 
the  nervous  system  becomes  still  further  impaired  and  is 
more  resistant  to  treatment.  In  certain  cases  there  is  loss  of 
the  sexual  appetence,  while  in  others — especially  those  in 
whom  there  is  cerebral  and  spinal  congestion — there  is  per- 
version of  this  sexual  function.  Patients  are  subject  to 
amorous  dreams  and  cohabitation  is  at  times  unsatisfactory, 
but  almost  invariably  natural  or  unnatural  gratification  is 
followed  by  increased  nervous  exhaustion.  This  is  the  his- 
tory of  the  derangement  of  function  which  arises  from  neu- 
rasthenia as  far  as  the  sexual  organs  are  concerned. 

In  regard  to  the  question  of  neurasthenia  itself,  of  which 
derangements  of  menstruation  are  established  symptoms,  I 
shall  reserve  what  I  have  to  say  until  I  come  to  consider  the 
nervous  exhaustion  when  it  is  caused  wholly  or  in  part  by 
diseases  and  derangements  of  the  sexual  organs. 

Causation. — That  this  amenorrhoea,  dysmenorrhoea,  or 
menorrhagia  is  caused  by  a  neurasthenia  is  evident,  first, 
from  the  fact  that  normal  innervation  is  an  important  es- 
sential to  the  performance  of    any  bodily  function,    and, 


184  MEDICAL  GYNECOLOGY. 

secondly,  that  there  is,  as  a  rule,  some  derangement  of  men- 
struation whenever  there  is  any  marked  disease  or  derange- 
ment of  the  nervous  system,  such  as  nervous  exhaustion. 
Furthermore,  in  cases  of  deranged  menstruation  associated 
with  nervous  exhaustion  normal  menstruation  is  usually  es- 
tablished as  soon  as  the  affections  of  the  nervous  system  are 
removed. 

Treatment.— It  is  evident  that  the  treatment  of  menstrual 
derangements  due  to  neurasthenia  must  be  directed  to  the 
latter  affection,  which  stands  in  a  causative  relation  to  the 
derangement  of  function.  I  shall  therefore  confine  my  re- 
marks for  the  present  to  the  management  of  the  patient 
during  the  menstrual  period,  and  refer  the  reader,  for  the 
subject  of  neurasthenia  and  other  affections  of  the  nervous 
system,  to  the  chapters  on  these  subjects. 

If  menstruation  is  scanty  it  is  judicious  to  encourage  a 
freer  flow,  especially  if  this  state  of  affairs  has  existed  for  a 
time.  The  same  indications  obtain  when  there  is  amenor- 
rhoea  with  a  marked  menstrual  molimen.  If  there  are  coex- 
istent anosmia  and  general  malnutrition,  diffusible  stimu- 
lants with  rest  will  give  a  certain  amount  of  relief.  Aromatic 
spirits  of  ammonia  and  camphor  water  with  cannabis  Indica 
will  often  increase  the  flow,  or  aid  in  bringing  it  on  if  it  Las 
been  entirely  absent.  In  case  there  is  pain  with  the  molimen 
or  the  scanty  flow,  the  addition  of  chloric  ether  often  gives 
the  most  marked  relief.  Should  there  be  cerebral  congestion, 
as  indicated  by  a  full  feeling  in  the  head  and  diffused  head- 
ache, with  considerable  vascular  tension,  backache,  general 
irritability,  and  sleeplessness,  bromide  of  sodium,  with  warm 
foot  baths  and  cooling  applications  to  the  head,  will  increase 
the  flow  or,  if  it  does  not  appear,  bring  it  about,  if  it  is  pos- 
sible to  do  so.  This  treatment  will  also  relieve  or  modify  the 
pain  to  a  great  extent.  In  case  there  is  menorrhagia,  digitalis 
with  small  doses  of  bromide  of  sodium  will  control  the-flow 
when  the  condition  is  attended  by  cerebral  hyperaemia.  In 
cases  associated  with  ansemia,  cannabis  Indica  with  aromatic 
sulphuric  acid  best  answers  the  purpose. 


DERANGEMENTS  OF  MENSTRUATION.  185 

MENSTRUAL  DERANGEMENTS  FROM   NERVOUS  EXHAUSTION 
FOLLOWING  PROLONGED   LACTATION. 

Lactation,  if  continued  for  a  great  length  of  time,  or  if 
complicated  with  general  taxation  from  mental  or  physical 
labor,  produces  a  form  of  nervous  exhaustion  which  I  think 
is  peculiar  to  this  function.  Angemia  also  appears  in  some 
cases  in  the  early  months  of  lactation,  and  general  pros- 
tration shows  itself  in  the  usual  way  by  rapid  pulse,  short- 
ness of  breathing  on  exercise,  flushings  of  the  face,  and 
general  lassitude.  The  symptoms  are  usually  sufficiently 
marked  to  drive  the  patient  to  seek  relief  ;  and  on  improving 
nutrition  and  giving  restorative  tonics,  and  having  the  patient 
abandon  all  other  duties  of  the  household  and  elsewhere,  the 
exhaustion  can  soon  be  overcome.  In  some  cases  where  the 
digestive  organs  do  not  act  vigorously  and  do  not  respond  to 
the  usual  remedies  for  enfeebled  digestion,  it  becomes  neces- 
sary to  wean  the  child.  The  fact  is,  that  those  cases  either 
recover  after  restorative  treatment,  or  are  obliged  to  give 
up  nursing,  and  this  is  sometimes  decided  before  the  pecul- 
iar nervous  exhaustion  characteristic  of  lactation  is  pro- 
duced. Of  course,  this  nervous  exhaustion  may  be,  and 
occasionally  is,  associated  with  anaemia,  but  I  have  very 
often  seen  it  in  a  marked  degree  where  nutrition  seemed  to 
be  fairly  good  ;  there  was  no  marked  anaemia,  nor  was  there 
any  extreme  muscular  debility — only  an  exhausted,  debili- 
tated condition  of  the  nervous  system,  characterized  by  dizzi- 
ness, temporary  loss  of  memory,  and  a  strange  feeling  in 
the  head,  which  rendered  the  patient  apprehensive  that  her 
mind  was  becoming  impaired. 

These  patients  have  also  attacks  of  mental  depression, 
and  are  at  times  emotional  without  being  able  to  give  any 
good  reason  for  this  mental  disturbance.  Timidity  becomes 
sometimes  oppressive  ;  and  often  they  are  haunted  by  a  fear 
that  something  is  going  to  happen  to  them,  or  that  they 
are  going  to  be  dangerously  ill  or  become  insane.  Fre- 
quently  they  have  intercostal  neuralgia   on  the  left  side, 


186  MEDICAL  GYNECOLOGY. 

whidi  at  once  leads  them  to  the  conclusion  that  they  must 
have  some  serious  heart  trouble.  This  is  especially  so  if 
they  have  attacks  of  palpitation  upon  being  startled  or 
when  taking  active  exercise.  Sometimes  they  are  sleepless 
during  the  night,  but  often  feel  drowsy  and  heavy  during 
the  day,  especially  after  eating.  This  trouble  of  the  nervous 
system  usually  comes  on  after  nursing  for  a  year  or  more, 
and,  as  a  rule,  without  menstruating.  Menstruation  gener- 
erally  returns  about  the  eighth  or  tenth  month,  although 
lactation  may  be  continued  ;  but  in  those  cases  of  exhaus- 
tion menstruation  seldom  recurs,  and  when  it  does  it  seems 
to  increase  the  nervous  disturbance.  Quite  frequently  in 
place  of  menstruation  a  continuous  leucorrhoeal  discharge 
comes  on. 

Causation. — Without  dwelling  upon  the  angemia  occur- 
ring in  the  early  months  of  lactation,  and  which  is  due  to 
ordinary  causes  or  an  excessive  demand  uidou  the  nutri- 
tive system,  I  shall  simply  consider  causes  which  produce 
this  nervous  exhaustion  which  is  not  infrequently  seen  un- 
complicated with  general  malnutrition  and  marked  anaemia. 
It  is  evident  to  my  mind  that  the  malnutrition  in  some  of 
those  cases  is  confined  largely,  if  not  entirely,  to  the  nerve 
centers,  and  that  this  is  probably  brought  about  chiefly 
because  human  milk  takes  from  the  mother  a  large  amount 
of  nerve  nutriment ;  but  this  may  hardly  be  suflicient  to 
account  for  the  malnutrition  of  the  nerve  centers  in  those 
who  have  abundant  food  supply  with  good  appetite  and 
digestion.  The  trouble  is  largely  aggravated  by  the  mental 
labor  and  worry  imposed  upon  mothers  in  taking  care  of 
their  household  and  children,  or,  if  they  have  means  to  free 
themselves  from  these  responsibilities  and  duties,  they  are 
mentally  taxed  by  the  demands  of  society  and  exercises  of 
an  intellectual  character.  More  than  this,  they  are  of  neces- 
sity much  disturbed  at  night  and  their  sleep  greatly  broken. 
This,  of  course,  obtains  to  the  greatest  extent  in  the  early 
months  of  lactation,  but  its  effect  is  shown  later ;  and  when 
the  time  comes  that  the  child  permits  the  mother  to  sleep 


DERANGEMENTS  OF  MENSTRUATION.  187 

she  has,  owing  to  her  nervous  debility,  become  almost  in- 
capable of  securing  it,  which  aggravates  her  trouble.  This 
seems  to  me  to  be  about  the  way  in  which  this  peculiar 
condition  is  brought  about. 

In  regard  to  the  treatment,  weaning  the  child  is  the  most 
important  indication,  and  the  trouble  usually  comes  about 
the  time  when  that  should  be  attended  to.  In  this  condition, 
as  indeed  in  all,  I  believe  that  gradual  weaning  is  by  far  the 
safest  and  most  salutary  for  both  mother  and  child,  and  I 
especially '  insist  upon  this,  because  patients,  when  made 
aware  of  the  fact  that  their  ailment  is  due  to  nursing,  are 
generally  anxious  to  abruptly  give  it  up.  This  I  believe  to 
be  unwise  and  unsafe.  I  therefore  advise  gradual  weaning, 
and  then  endeavor,  by  an  abundant  supply  of  good,  nour- 
ishing food,  by  stimulating  the  appetite  by  tonics  if  need 
be,  aiding  digestion  if  that  is  necessary,  and  by  the  use  of 
restoratives,  to  effect  a  return  to  the  normal.  When  the 
nervous  disturbances — despondency,  apprehensions,  excita- 
bility, and  sleeplessness — are  such  as  to  be  at  all  alarming,  I 
have  found  that,  as  soon  as  the  child  has  been  weaned,  very 
small  doses  of  opium  (by  that  I  mean  enough  to  give  a  sus- 
taining, not  an  anodyne  effect)  to  be  remarkably  serviceable. 
After  the  use  of  the  opium,  or  during  its  administration,  I 
have  been  in  the  habit  of  giving  what  has  by  some  been  called 
brain  food,  and  by  that  I  mean  the  fats  and  all  articles  that 
are  rich  in  phosphates,  and  then  adding  in  the  way  of  medi- 
cines some  of  the  preparations  of  phosphates.  In  the  early 
days  of  my  practice  I  was  taught  to  use  the  pyrophosphate  of 
iron,  and  I  still  find  it  efficient.  I  also  use  the  old  Parrish's 
compound  sirup  of  phosphate  with  advantage,  giving  these 
remedies  after  meals.  Strychnia,  at  the  beginning  of  the 
treatment,  sometimes  gives  a  good  deal  of  relief,  but  usually 
requires  to  be  given  in  good-sized  doses — from  one  thirtieth  to 
one  fortieth  of  a  grain  three  times  a  day.  Regarding  alcohol 
in  these  cases,  its  use  or  not  must  be  settled  according  to  the 
nature  of  the  case.  I  have  found  that  many  of  those  who 
suffer  the  most  have  used  beer  and  wine,  sometimes  spirits, 

13 


188  MEDICAL  GYNECOLOGY. 

during  lactation,  hoping  that  it  would  enable  them  to  main- 
tain their  strength.  In  such  cases  I  find  that  it  is  well  to  with- 
hold it,  for,  if  they  lose  their  nerve  force  or  strength  while 
using  alcohol,  it  usually  fails  to  restore  them  when  the  drain 
or  the  taxation  of  nursing  has  ceased.  With  those  who 
have  been  in  the  habit  of  using  stimulants  it  is  well  to 
try  a  little  wine  with  meals ;  or  if  the  patient  is  spare  of 
habit — a  sensitif  with  not  a  very  good  appetite — a  good  ale 
will  sometimes  aid  digestion,  and  have  a  sustaining  and  seda- 
tive effect.  But  all  stimulants  should  simply  be  tried  and 
their  effect  watched.  It  is  impossible  to  tell  whether  they 
will  do  good  or  harm  until  after  the  trial.  Mental  rest  with 
sufficient  out-of-door  air  and  exercise  should  be  prescribed. 
In  obstinate  cases  absolute  rest  with  massage,  central  galvan- 
isation, and  the  restorative  remedies  already  referred  to, 
should  be  resorted  to. 


CHAPTER  XYI. 

DEEANGEMENTS   OF  THE   SEXUAL   FUNCTION. 

Peemature  excitation  of  the  sexual  function  is  occasion- 
ally seen  at  a  very  early  age.  I  have  seen  cases  in  practice, 
and  know  that  there  are  many  others  recorded,  of  masturba- 
tion in  children  of  from  two  years  and  upward.  This,  I  be- 
lieve, is  rare  at  so  early  an  age,  and  yet  they  are  seen  perhaps 
as  often  among  quite  young  children  as  at  any  other  time, 
excepting  just  about  the  time  of  puberty.  When  this  per- 
version of  the  sexual  function  occurs  in  very  early  life  it  is 
more  easily  detected,  because  the  patient,  as  a  rule,  has  not 
intelligence  enough  to  conceal  her  unnatural  behavior.  I 
have  known  mothers  to  observe  this  curious  behavior  on 
the  part  of  their  children,  and,  as  sooner  or  later  it  is  at- 
tended with  ill  health,  they  seek  counsel  and  describe  those 
actions  on  the  part  of  the  patient,  sometimes  knowing,  at 
other  times  not  knowing  what  it  really  means.  The  chil- 
dren who  suffer  from  this  affection  usually  become  debili- 
tated, anaemic,  have  indigestion,  a  fretful  temper,  are  inact- 
ive and  lack  interest  in  things  about  them,  and  are  morbid 
and  gloomy.  They  suffer  also  from  headache  and  prefer  to 
be  alone— if  not  all  the  time,  yet  at  times.  When  a  history 
of  this  kind  is  given  which  does  not  include  an  account  of 
the  practicing  of  this  bad  habit,  the  suspicions  of  the  physi- 
cian can  be  confirmed  by  asking  the  mother  or  attendant 
to  watch  and  see  whether  the  patient  is  disposed  to  handle 
the  genitals  or  to  cause  excitation  by  friction  against  the 
corner  of  a  chair  or  the  table,  or  by  sitting  and  moving  to 
and  fro  on  a  chair.     This  is  sufficient  to  confirm  the  diag- 

189 


190  MEDICAL  GYNECOLOG-Y. 

nosis,  especially  if,  after  this  performance  is  over,  the  child 
is  found  in  an  excited  state  and  bathed  in  perspiration. 

Causation. — From  observations  of  the  cases  that  I  have 
seen,  I  am  inclined  to  believe  that  there  is  considerable 
heredity  underlying  this  affection,  at  least  as  a  predispos- 
ing cause.  The  more  direct  causes  are,  no  doubt,  irritation 
about  the  vulva  from  lack  of  cleanliness,  or  a  vulvitis  caused 
by  exposure  to  cold.  Ascarides,  haemorrhoids,  rectal  fissure, 
eczema  about  the  anus,  or  erythema  are  said  to  be  frequent 
causes.  I  know  also  that  adhesions  of  the  prepuce  to  the 
glans  clitoridis,  by  which  the  secretions  are  imprisoned,  is  a 
cause  of  irritation.  I  am  inclined  to  think  that  this  plays 
a  far  more  important  part  in  producing  this  affection  than 
is  generally  believed  among  practitioners.  I  have  no  doubt 
that  this  habit  is  quite  frequently  learned  from  depraved 
associates,  and  especially  is  this  true  among  the  older  girls. 
I  have  recently  seen  a  patient  who  found  that  a  certain  gym- 
nastic exercise  produced  this  morbid  gratification. 

Treatment. — When  the  diagnosis  has  been  made  with  a 
reasonable  degree  of  certainty,  the  cause  should  be  sought 
for  and,  when  discovered,  removed.  If  the  patient  is  sus- 
pected of  suffering  from  ascarides,  relief  will  be  promptly 
obtained  by  using  for  a  few  days  salt-water  injections  after 
each  time  that  the  bowels  move,  and  then  every  second  or 
third  day  afterward.  Meanwhile  the  state  of  the  bowels  and 
digestive  organs  generally  should  be  corrected  in  case  they 
are  out  of  order,  as  they  usually  are.  Haemorrhoids  or  fis- 
sure should  be  treated  at  once  by  surgical  means.  If  any 
eruptive  disease  be  found,  it  should  be  relieved  in  the  usual 
way.  Should  a  subacute  inflammation  exist  about  the  vulva, 
that  will  require  treatment  by  keeping  the  parts  thoroughly 
clean,  and,  after  bathing,  dusting  the  parts  over  with  sub- 
gallate  of  bismuth,  which  I  find  to  be  one  of  the  best  appli- 
cations. This  is  a  recently  introduced  remedy,  but  has  acted 
remarkably  well  in  my  hands.  Formerly  I  employed  a  mild 
solution  of  nitrate  of  silver,  one  grain  to  the  ounce,  thor- 
oughly applied  with  an  atomizer  every  second  or  third  day. 


DERANGEMENTS  OP  THE  SEXUAL  FUNCTION.  191 

and  in  the  meantime  the  parts  were  dusted  over  with  bis- 
muth and  chalk.  In  case  there  is  any  adhesion  of  the  pre- 
puce, it  should  be  separated  and  the  parts  that  were  adher- 
ent dusted  over  with  i)owder  of  subgallate  of  bismuth  or 
iodoform,  preferably  the  former.  When  all  evidences  of 
local  irritation  have  been  removed  and  the  patient's  general 
health  is  restored,  there  is  often  a  marked  diminution  in 
disposition  on  the  part  of  the  little  one  to  practice  this 
abuse,  but,  as  a  rule,  it  does  not  by  any  means  cure  the 
patient.  '  Absolute  and  continuous  watchfulness  on  the  part 
of  the  mother  or  attendant  is  the  only  way  to  eradicate  the 
tendency.  This  must  not  be  for  a  week  or  a  month,  but, 
if  necessary,  for  years.  Such  a  patient  should  never  be  left 
alone  night  or  day.  She  should  be  attended  while  out  of 
doors  and  at  play.  Of  course,  in  school  she  will  be  under 
the  observation  of  her  classmates  and  teacher,  which  will  be 
a  restraining  power,  but  at  all  other  times  an  attendant  must 
watch  her ;  especially  she  should  never  be  allowed  to  go  to 
the  bath  room  or  closet  without  having  the  door  of  the  room 
open  so  that  the  attendant  can  observe  her. 

In  one  of  the  worst  cases  of  the  kind  that  I  have  ever  seen 
the  patient  was  greatly  improved  when  summer  came,  after  a 
winter's  treatment  and  observation,  and  she  was  taken  to  the 
country,  where,  under  the  change  and  with  new  attractions, 
out-of-door  air,  and  constant  watching,  she  completely  re- 
covered. On  returning  home,  however,  she  was  incliiied  to 
resume  the  habit,  probably  because  of  association,  so  that 
exceedingly  great  care  was  necessary  during  the  season.  I 
believe  that  she  entirely  recovered,  but  became  somewhat  im- 
moral in  her  doings  after  attaining  her  majority ;  at  least 
that  is  the  report  I  received  from  her  physician. 

While  watching  and  restraining  those  patients,  as  one 
would  care  for  an  insane  person,  I  must  suggest  that  cor- 
poral punishment  should  be  avoided,  especially  the  old- 
fashioned,  but  I  hope  now  obsolete,  method  of  spanking. 
Many  observers  in  the  profession  have  declared  that  this 
punishment  often  produces  irritation  of  the  genitals,  and  I 


192  MEDICAL  GYNECOLOGY. 

believe  it  to  be  true.  A  cultivated,  intelligent  mother,  at- 
tendant, or  teacher  can  accomplish  a  great  deal  by  sugges- 
tion— that  is,  by  drawing  the  attention  of  the  little  one  to 
matters  of  interest  outside  of  herself  and  her  emotions ;  and 
much  also  can  be  done  in  the  way  of  cultivating  the  will  and 
self-respect. 

EXCESS  IN  THE  NATURAL  OR  UNNATURAL  EXERCISE  OF 
THE  SEXUAL  FUNCTION. 

While  it  is  well  understood  that  the  excess  of  the  sexual 
function  after  puberty,  especially  after  majority,  is  attended 
with  the  same  baneful  effects  as  the  normal  excess  of  any 
other  function,  it  has  been  also  claimed  by  some  medical 
men  who  have  given  attention  to  this  subject  that  the  un- 
natural exercise  of  the  natural  function,  if  not  carried  to  ex- 
cess, is  not  attended  with  such  marked  damaging  effects  on 
the  general  health  as  would  be  supposed.  I,  however,  take 
the  ground  that  perverted  sexual  function  certainly  is  more 
injurious,  and  is  far  more  likely  to  be  carried  to  excess,  than 
the  normal  exercise  of  the  function.  In  either  case,  however, 
the  effect  is  to  produce  nervous  and  general  exhaustion. 
Such  cases  are  often  characterized  by  a  vigorous,  even  mor- 
bid appetite,  and  very  often  by  a  reasonably  good  digestion  ; 
but  assimilation  is  not  sufficient  to  maintain  the  balance  of  a 
wholesome  nutrition  ;  hence  the  patients  become  anaemic, 
often  spare  of  habit,  and  are  physically  incompetent,  as 
shown  by  the  fact  that  they  are  most  easily  fatigued  and  ex- 
hausted. While  this  is  true  of  the  mnscular  and  circulatory 
systems,  it  is  perhaps  more  marked  in  regard  to  the  nervous 
system.  Neurasthenia  or  nervous  exhaustion  of  a  peculiar 
form  is  observed.  There  is  a  marked  inability  to  do  brain 
work,  and  concentration  of  the  mind  is  exceedingly  difficult ; 
or,  if  the  patient  can  control  the  mind  and  secure  application 
of  it  to  a  subject,  exhaustion  and  weariness  soon  supervene, 
and  are  very  often  followed  by  headache.  Mental  inertia  is 
then  a  prominent  symptom,  and  if  an  effort  is  made  to  exer- 
cise the  mind  it  often  results  in  producing  great  irritability 


DERANGEMENTS  OF  THE  SEXUAL  FUNCTION.  193 

or  an  irascible  temper.  At  first  sleep  is  usually  good  ;  in 
time  it  is  apt  to  become  imperfect.  If  such  patients  are  at 
all  excited  on  retiring  to  rest,  sleep  does  not  come ;  or  if 
they  get  to  sleep  readily  and  sleep  well,  they  will  occasion- 
ally have  wakeful  nights. 

It  will  be  seen  that  the  symptoms  described  in  neuras- 
thenia and  general  debility  are  unaccounted  for  by  any  other 
cause.  This  general  exhaustion  differs  in  no  way  from  the 
same  general  affection  from  other  causes  except  in  one  thing. 
In  young' people  I  have  noticed  that  their  strength  fluctu- 
ates ;  that  they  will  for  a  time  manifest  great  exhaustion,  and 
in  a  few  days  they  will  begin  to  pick  up  strength,  both  men- 
tally and  physically,  and  appear  to  be  almost  well,  and  then 
all  at  once  they  drop  down  again.  Presumably  this  varia- 
tion depends  upon  the  excess  which  gives  rise  to  it.  Conti- 
nence for  a  short  time  will  enable  the  patient  to  regain 
strength,  while  a  recurrence  of  the  indulgence  will  promptly 
produce  marked  debility. 

This  affection  is  usually  seen  among  young  people,  and 
the  diagnosis  is  not  easily  made.  It  is  exceedingly  difficult 
to  make  a  positive  diagnosis,  because  it  is  not  always  prudent 
to  make  inquiries  concerning  this  special  function,  and  for 
this  reason  :  if  inquiry  is  made  and  the  patient  is  not  suffer- 
ing from  this  excess,  no  information  will  be  obtained,  because 
the  patient  will  not  understand  the  question.  If  they  are, 
they  will,  as  a  rule,  pretend  that  they  do  not  understand  the 
question,  or  deny  the  fact  even  if  they  do  understand  it. 
One  is  then  very  often  left  in  some  doubt ;  but  if  the  patient 
is  young  and  unmarried,  the  mother  or  guardian  may  be  ad- 
vised to  see  that  she  behaves  herself,  and  in  the  case  of  young 
married  women  information  can  be  obtained  from  the  asso- 
ciates in  the  family.  The  causes  are  in  the  great  majority  of 
cases  due  to  ignorance.  The  sexual  instinct  craves  attention, 
and  the  patient  is  unwitting  of  the  consequences  of  overin- 
dulgence or  abnormal  gratification,  and  hence  suffers.  In 
some  the  cause  no  doubt  arises  from  a  precocious  or  over- 
stimulated  emotional  nature.     In  others  local  diseases  of  the 


194  MEDICAL  GYNECOLOGY. 

sexual  organs,  and  rectal  diseases  such,  as  were  mentioned 
in  speaking  of  the  same  affection  among  children,  are  the 
causes,  but  I  think  that  those  local  diseases  are  exceedingly 
rare  as  causes  of  these  bad  habits.  On  the  other  hand,  I 
believe  that  the  perversion  of  this  function  very  often  leads 
to  disease  of  the  sexual  organs. 

Treatment. — The  treatment  of  this  class  of  cases  may  be 
briefly  given.  In  the  first  place,  to  stop  the  indulgence  in 
those  that  are  single,  and  to  modify  it  in  the  other  class — that 
is,  to  reduce  the  indulgence  to  the  capacity  of  the  patient  to 
endure  it.  Then  the  treatment  to  restore  the  general  health 
must  be  conducted  on  general  principles.  To  enable  those  to 
accomplish  the  desired  object  it  is  sometimes  necessary  to 
give  bromide  in  order  to  control  the  sexual  excitation.  This 
should  be  given  in  the  afternoon  and  evening,  so  as  to  secure 
perfect  rest  at  night,  and  the  day  should  be  devoted  to  the 
use  of  tonics  and  good  nourishment,  and,  above  all,  whole- 
some mental  and  physical  occupation  carried  as  far  as  can  be 
without  fatiguing  or  wearying  the  patient.  If  they  are  un- 
able to  endure  mental  and  physical  exercise  for  any  length 
of  time,  short  stages  of  rest  and  equally  short  stages  of  ex- 
ercise should  be  enjoined,  so  as  to  enable  the  patient  to  do 
all  she  is  capable  of  doing  without  adding  thereby  to  her 
general  exhaustion, 

MORBID   SEXUAL  APPETENCE. 

That  there  are  a  few  women  who  are  morbidly  amorous  I 
believe  ;  but  they  are  exceedingly  few  compared  with  those 
who  are  almost  destitute  of  this  sexual  appetence.  Cases 
that  are  tormented  by  strong  desires  which  they  do  not  in- 
dulge are  apt  to  be  obtrusive  in  society,  and  to  be  considered 
by  their  neighbors  as  rather  loud  in  habit  and  manner. 
They  are  often  subject  to  attacks  of  a  certain  form  of  hys- 
teria, which  shows  itself  for  a  time  in  the  way  of  explosions 
of  hysterical  attacks  which  pass  off  and  the  patient  appear 
to  be  tolerably  well,  the  attacks  being  brought  on  by  excite- 
ment in  company  or  by  active,  agreeable,  or  taxing  occupa- 


DERANGEMENTS  OF  THE  SEXUAL  FUNCTION.  195 

tion.  The  cause  of  this  condition  I  believe  to  be  entirely  a 
peculiarity  of  the  mental  and  physical  organization.  The 
transmitted  emotional,  mental  organization  is  usually,  though 
not  always,  associated  with  robust  physical  health.  It  is 
true,  of  course,  that  this  can  be  cultivated  by  unfavorable 
associations  and  by  an  education  which  appeals  to  the  emo- 
tions at  the  expense  of  the  culture  of  the  will.  Lack  of 
occupation  of  a  wholesome  character  has  no  doubt  much  to 
do  with  this.  The  old  saying  that  "idle  hands  readily  find 
mischief  to  do"  applies  with  perhaps  greater  force  to  the 
sexual  system  and  idle  minds. 

Treatment. — The  most  important  factors  in  the  treatment 
are  wholesome  occupation,  avoidance  of  exciting  and  frivo- 
lous company,  and  cultivation  of  the  will  power.  Bromides 
are  to  be  given  to  quiet  all  mental  disturbances,  as  far  as  this 
can  be  done  without  producing  any  of  the  ill  effects  of  the 
remedy.  The  bowels  should  be  kept  free  by  the  use  of  saline 
cathartics  -or  laxatives  given  early  in  the  morning.  Cold 
sponge  or  shower  baths  in  the  morning  and  a  warm  sponge 
or  plunge  bath  at  night  are  very  often  followed  by  good  re- 
sults, I  believe  by  attention  to  such  cases  much  benefit  can 
be  derived  and  valuable  women  may  be  saved  from  going  to 
destruction  by  a  reasonable  physical  and  mental  education, 
with  the  Judicious  use  of  a  few  remedial  agents  such  as  have 
been  mentioned. 

CONTINENCE,   OR   SEXUAL   STARVATION. 

According  to  my  observation,  women  who  have  attained 
their  majority  without  having  had  the  sexual  instinct  awak- 
ened either  by  evil  associates,  their  own  sex,  by  courtship,  or 
by  marriage,  may  go  through  life  without  having  any  dis- 
turbance whatever  from  the  sexual  organs.  Those,  however, 
who  have  been  married  and  have  early  in  life  become  wid- 
owed, have  much  suffering  from  this  continence,  which,  if 
not  relieved  or  overcome,  often  leads,  no  doubt,  to  ill  health, 
to  say  nothing  of  immoralities.  Those  who  are  in  good 
health  are  as  likely  to  suffer  as  those  that  are  more  delicate. 


196  MEDICAL  GYNECOLOGY. 

the  woman  becoming  restless,  irritable,  often  sleepless,  and 
subject  to  acute  attacks  of  indigestion  and  to  headache.  In 
some  cases  if  the  conditions  are  maintained,  endometritis  and 
leucorrhoea  are  developed.  Menstruation  also  may  be  de- 
ranged. 

In  regard  to  the  causation,  nothing  need  be  said,  except 
that  the  most  distressing  cases  are  found  among  unfortunate 
women  who  marry  men  who  have  been  rendered  incompetent 
by  excess  and  bad  habits.  All  the  laws  of  Nature  say  that 
such  women  should  be  liberated,  the  state  and  church  laws 
to  the  contrary. 

Treatment. — The  treatment  of  those  cases  demands,  as 
in  the  former  class,  healthful  occupation  without  excessive 
taxation.  This  is  of  prime  importance.  Here  the  bromides 
should  be  used  as  I  suggested,  and  baths  and  saline  laxa- 
tives also.  In  case  there  are  general  exhaustion  and  anaemia, 
which  are  sometimes  observed  in  delicate  women,  or  if  these 
general  conditions  are  produced  by  the  morbid  emotions, 
general  tonic  treatment  is  necessary.  Perhajps  one  of  the 
most  important  remedies  in  such  cases  is  strychnine.  In  the 
morbid  conditions  which  we  have  endeavored  to  briefly  out- 
line we  find  two  classes  associated  with  the  various  abnormal 
states  of  the  sexual  organs — the  asthenic  and  the  sthenic. 
The  asthenic  require  tonic  treatment,  good  nourishment, 
light  exercise,  agreeable  occupation,  and  strychnine.  The 
sthenic  require  bromides,  mental  and  physical  exercise  and 
occupation  that  can  be  well  borne,  protection  from  morbid 
excitement,  and  the  full  benefit  of  hydropathy. 

SEXUAL  FRIGIDITY,   OR  SEXUAL  ANESTHESIA. 

Two  classes  of  cases  come  under  this  heading :  First, 
those  who  are  without  sexual  desire  ;  and,  second,  those 
having  desire  in  a  mild  degree,  but  who  receive  no  gratifi- 
cation. 

The  first  class  are  either  defective  in  their  sexual  organs, 
in  which  case — ^being  incurable — they  should  not  marry  ;  or 
the  sexual  feeling  may  be  dormant,  and  conjugal  obligations 


DERANGEMENTS  OP  THE  SEXUAL  FUNCTION.  197 

fulfilled  simply  as  a  duty.  A  strong  affection  for  their  part- 
ners may  develop  the  feeling  in  some  ;  and,  again,  it  may  re- 
main latent. 

Faulty  education  and  association  are  often  the  cause. 
Some  grow  up  without  affection  or  the  need  of  it,  and  acquire 
the  habit — if  married — without  reciprocal  sexual  attentions. 
Other  cases,  under  opposite  conditions,  acquire  perverted 
sexual  habits. 

Sometimes— indeed,  not  infrequently — the  vulva  is  tender, 
or  the  prepuce  of  the  clitoris  is  adherent,  in  which  case  local 
treatment  is  indicated.  Some  cases  are  benefited  by  cannabis 
Indica  and  nux  vomica,  others  are  helped  by  alcohol.  The 
great  thing  is  to  awaken  desire  by  caressing  demonstrations 
of  affection. 

The  second  class  are  more  easily  cured,  provided  the 
husband  can  be  educated  up  to  a  necessary  degree  of  self- 
control.  In  most  of  these  cases  the  husband  has  availed  him- 
self of  conjugal  privileges  until  he  has  become  altogether 
too  expeditious,  while  the  wife  requires  more  time  than  is 
afforded  ;  the  cause  in  this — as  in  many  other  conditions — is 
a  want  of  harmony  between  the  parties  united. 

The  most  unfortunate  are  those  who  have  the  sexual  ap- 
petence ;  they  experience  excitation,  but  receive  no  gratifica- 
tion. Such  women,  when  married  and  subjected  to  repeated 
excitation  without  relief,  become  mentally  depressed,  and 
finally  exhausted  and  melancholy.  The  treatment  in  such 
cases  should  be  directed  to  the  other  member  of  the  family. 
This  brings  up  the  subject  of  unsuitable  unions,  and  certain 
conditions  of  both  sexes  which  forbid  or  should  contra- 
indicate  marriage.  The  advice  of  the  physician  is  seldom 
sought  upon  this  important  subject,  but  he  should  be  pre- 
pared to  advise  wisely  when  called  upon  to  do  so. 

The  rule  which  I  have  followed  in  a  general  way  is  that 
all  decided  organic  diseases  of  the  sexual  organs  which  may 
interfere  with  the  exercise  of  these  functions,  especially  if 
incurable,  is  a  barrier  to  marriage.  Functional  diseases  and 
the  non-specific  infiammatory  affections  do  not  stand  in  the 


198  MEDICAL  GYNECOLOGY. 

way  of  union.  Regarding  the  Tiabit  of  masturbation,  wMle 
it  unqualifies  women  to  a  limited  extent,  it  is  not  a  strong 
objection.  Women  given  to  this  habit,  while  they  may  not 
be  responsive  to  the  opposite  sex,  do  not  suffer  or  cause  suf- 
fering to  any  extent. 

It  is  otherwise  with  men.  Those  who  from  bad  habits 
have  become  incompetent,  and  can  not  be  cured  by  proper 
treatment,  should  be  prohibited  from  marrying.  At  any 
rate,  the  physician  should  point  out  to  such  that  they  are  in 
danger  of  ruining  the  lives  of  others  as  well  as  their  own 
happiness.  They  generally  follow  their  own  inclinations,  but 
they  generally  meet  their  reward.  This  latter  need  not  be 
regretted,  were  it  not  that  the  other  sex  suffer. 


CHAPTER  XVII. 

ACUTE   IlSrrLAMMATOEY    AFFECTIONS    OF   THE    PELVIC   OEGAlSrS. 

Theee  are  two  classes  of  inflammatory  affections  of  the 
pelvic  organs— the  acute  and  the  chronic.  They  differ  so  in 
their  pathology  and  results,  and  in  their  influence  upon  the 
nutritive  and  nervous  systems,  that  they  require  to  be  dis- 
cussed as  entirely  different  affections,  although  belonging  to 
the  same  order.  I  shall  first  consider  the  acute  inflamma- 
tions. 

Acute  inflammation  of  tbe  uterus.  Fallopian  tubes,  ovaries, 
pelvic  peritonaeum,  cellular  tissues,  and  lymphatics  are  all 
distinct  diseases,  and  are  treated  of  separately  in  works  on 
the  subject. 

I  find,  however,  that  all  of  these  affections  have  very  much 
in  common  in  their  pathology,  clinical  history,  and  treatment. 
Two  or  more  of  these  affections  often  occur  together ;  at  all 
times  it  is  difficult  to  make  an  accurate  and  differential  diag- 
nosis, and  it  is  impossible  in  the  most  complicated  cases. 
Under  these  circumstances  the  physician  must  deal  vdth  the 
pathological  conditions  as  a  whole,  and  manage  them  as  one 
affection.  The  general  therapeutics  of  one  applies  to  aE. 
The  nervous  system  may  be  more  profoundly  impressed  in 
ovaritis,  for  example,  than  in  cellulitis,  and  the  nutritive  sys- 
tem, especially  the  digestive  system,  may  suffer  most  in 
pelvic  peritonitis;  but  the  difference  is  in  degree,  not  in 
kind.  The  acute  pelvic  inflammations  are  generally  said  to 
belong  to  surgery;  but  they  come  largely  into  the  depart- 
ment of  medicine. 

Many  of  these  affections  in  their  advanced  stages  require 

199 


200  MEDICAL  GYNECOLOGY, 

surgical  treatment,  but  some  of  them  can  be  carried  through, 
to  recovery  by  medical  treatment,  and  they  all  require  medi- 
cal care  to  a  great  extent. 

Up  to  the  present  time  the  line  which  divides  medicine 
and  surgery  in  the  treatment  of  pelvic  inflammations  has  not 
been  clearly  pointed  out ;  and  yet  it  is  often  very  important 
to  draw  that  line  clearly,  in  order  to  know  when  and  how 
long  to  depend  ui:)on  medical  treatment,  and  when  surgical 
aid  is  called  for. 

Ignoring  the  overcareful  physician  who  depends  upon  his 
drugs  to  do  impossible  things,  and  the  overenthusiastic  sur- 
geon who  in  every  pelvic  affection  finds  an  indication  for  sur- 
gical interference,  one  may  be  able  to  lay  hold  of  certain  facts 
which  will  guide  to  wise  decisions  on  this  subject.  My  own 
opinion  is  that,  so  long  as  a  case  of  pelvic  inflammation  is 
progressing  so  that  there  is  no  apparent  danger  to  the  life  of 
the  patient,  and  there  are  good  prospects  that  recovery  will 
come  in  time,  medical  care  is  most  to  be  relied  wpon ;  but 
when  suppuration  takes  place,  no  matter  where,  in  the  pelvis, 
then  surgery  comes  in  to  do  what  medicine  can  not  do.  In 
cases  that  do  badly,  even  when  there  is  no  certainty  of  the 
presence  of  pelvic  abscess,  but  a  possible  general  septicae- 
mia, surgical  treatment  is  called  for.  There  are  other  cases 
that  recover  from  the  acute  disease  ;  but  the  products  of  the 
inflammation,  in  peritonitis  for  example,  may  be  of  such  a 
nature  that  the  pelvic  organs  are  so  damaged  by  adhesions, 
induration,  or  compression  that  they  can  not  continue  their 
functions,  and  the  patient  is  rendered  useless  and  suffers  se- 
verely. Such  cases  may  come  within  the  reach  of  surgery 
when  medicine  is  incapable  of  bringing  relief.  While  the 
physician  may  succeed  in  the  majority  of  such  cases,  he 
should  be  prepared  to  promptly  discover  those  conditions 
which  can  only  be  handled  by  the  surgeon.  An  equal  re- 
sponsibility rests  with  the  surgeon  in  determining  the  limits 
of  his  calling  in  the  treatment  of  such  cases. 


ACUTE  INFLAMMATION  OF  THE  PELVIC   ORGANS.  201 


GSNERAL  PATHOLOGY  OF    ACUTE    INFLAMMATION   OF    THE 

PELVIC  ORGANS. 

Acute  inflammation  is,  in  its  essential  elements,  always 
the  same.  The  process  is  modified  in  many  important  ways 
by  the  nature  of  the  tissue  and  the  cause  which  gives  rise  to 
it.  For  example,  acute  inflammation  of  the  lymphatics,  cel- 
lular tissue.  Fallopian  tubes,  and  ovaries  is  always  likely  to 
go  on  to  suppuration  and  the  formation  of  abscess.  Pelvic 
peritonitis'  usually  ends  at  the  stage  of  exudation.  There 
are,  however,  exceptions  in  all  cases.  The  final  results  differ 
according  to  the  parts  affected  and  the  causes. 

Instead  of  giving  here  a  full  account  of  the  pathology 
of  inflammation  of  the  special  organs  now  under  considera- 
tion, it  will  suffice  for  the  present  to  mention  some  of  the 
general  characteristics  of  pelvic  inflammation  and  the  condi- 
tions produced  thereby  that  come  under  the  observation  and 
care  of  the  physician.  This  is  the  most  useful  knowledge  for 
the  medical  practitioner. 

Deranged  innervation  and  congestion  constitute  the  first 
steps  in  the  inflammatory  process.  Next  in  order  come  the 
products  or  results  of  it — that  is  to  say,  the  transudation 
and  exudation  of  inflammation.  In  certain  cases  the  pro- 
cess stops  before  the  more  highly  organized  products  or  exu- 
dates appear — I  refer  to  cases  that  end  in  resolution.  Others 
go  on  to  suppuration.  In  others  still  the  exudation  goes  on 
to  the  fullest  possible  extent  and  forms  adhesions  and  indu- 
rations, and  thereby  damages  the  pelvic  organs  less  or  more. 
In  all  of  these  inflammations  suppuration  may  or  may  not 
take  place.  The  occurrence  of  suppuration  marks  the  bound- 
ary line,  as  a  general  rule,  between  those  that  require  medical 
treatment  only  and  those  that  require  both  medical  and  sur- 
gical care.  So  long  as  there  is  no  formation  of  pus  in  the 
pelvis,  there  is  no  urgent  demand  for  surgical  operations. 
An  exception  to  this  rule  is  met  when  the  damage  done  by 
the  products  of  inflammation — such  as  adhesions — affects  the 
functions  of  the  pelvic  organs  so  that  the  life  of  the  patient 


202  MEDICAL  GYNECOLOGY. 

is  in  danger,  or  renders  her  helpless  and  useless,  and  medical 
treatment  fails  to  give  relief. 

The  duration,  termination,  and  after-consequences  of  pel- 
vic peritonitis  depend  largely  upon  the  extent  of  the  inflam- 
mation and  the  cause  which  gives  rise  to  it.  In  some  cases, 
where  the  exudation  is  limited,  recovery  will  take  place  in  a 
few  weeks,  and  but  little  after  ill  effects  will  be  noticed,  ex- 
cept occasional  pain  from  time  to  time  in  the  region  of  the 
exudate.  In  other  cases,  where  the  whole  pelvic  peritonaeum 
is  involved,  the  fimbriated  extremities  of  the  Fallopian  tubes 
become  involved  in  the  exudate,  and  are  virtually  destroyed. 
If  this  includes  both  sides,  the  function  of  the  ovaries  and 
tubes  is  arrested  because  of  the  damage  to  the  structure. 

Degeneration  of  the  ovaries  often  follows  under  these  cir- 
cumstances ;  sometimes  they  become  inflamed  and  succu- 
lent ;  at  other  times  they  become  atrojjhied — due,  no  doubt, 
to  the  pressure  of  the  contracting  exudate  and  the  interrup- 
tion of  the  circulation  in  them  ;  in  short,  in  some  of  these 
cases  the  adhesions  and  the  quantity  of  exudation  so  destroy 
the  anatomical  relations  that  on  post  mortem  it  is  almost  im- 
possible to  recognize  the  tissues  or  organs.  A  mass  of  tangled 
adhesions  and  products  of  inflammation,  covering  the  uterus 
and  broad  ligaments,  is  about  all  that  can  be  made  out. 

When  such  patients  live,  they  suffer  greatly  from  pelvic 
pain  and  dysmenorrhoea,  if  the  function  of  menstruation  is 
not  arrested,  as  it  sometimes  is,  by  the  destruction  of  the 
ovaries. 

In  discussing  the  clinical  history  of  these  acute  inflamma- 
tions an  effort  will  be  made  to  point  out  the  ways  and  means 
of  detecting  the  most  important  states  or  stages  of  the  pro- 
cess and  their  bearing  upon  treatment. 

Symptomatology. — In  all  forms  of  acute  inflammation  of 
the  pelvic  organs  there  are  symptomatic  fever,  pelvic  pain, 
and  derangement  of  the  functions  of  the  pelvic  organs  to 
some  extent. 

There  is  a  great  variation  in  the  symptoms  in  different 
cases  ;  the  local  lesions  differ  in  degree  and  extent,  so  the 


ACUTE  INFLAMMATION   OF   THE   PELVIC   ORGANS.  203 

symptoms  vary  in  their  severity.  There  is  a  decided  symp- 
tomatic fever,  as  indicated  by  the  frequency  of  pulse  and 
elevation  of  temperature.  This  may  or  may  not  be  preceded 
by  a  chill  or  rigor,  which  is  promptly  followed  by  fever. 

The  temperature  ranges  from  101-5°  F.  to  104°  F.  There  is 
also  marked  derangement  of  the  digestive  organs  ;  sometimes 
there  are  nausea  and  vomiting,  almost  always  tympanitic 
distention  of  the  bowels,  and  usually  constipation.  There 
are  derangement  and  depression  of  the  nervous  system,  but 
rarely  delirium.  The  patient  usually  complains  of  pain,  the 
intensity  of  which  varies  considerably  ;  it  is  usually  most 
marked  in  peritonitis  and  ovaritis. 

The  disturbance  of  the  function  of  the  pelvic  organs  de- 
pends upon  the  organs  involved. 

If  the  attack  comes  on  when  the  menstrual  period  is  near, 
there  may  be  menorrhagia.  There  is  also  quite  often  vesical 
and  rectal  tenesmus.  There  is  tenderness  on  deep  pressure 
in  the  iliac  regions,  and  the  pain  is  usually  aggravated  by 
any  movement  on  the  part  of  the  patient.  This  usually  com- 
pels the  sufferer  to  rest  quietly  on  the  back,  and  some  relief 
is  obtained  by  drawing  up  the  limbs.  This  position  is  most 
certainly  assumed  and  persistently  maintained  in  peritonitis. 
These  symptoms,  both  general  and  local,  usually  continue 
without  much  modification,  except  that  relief  which  may  be 
obtained  through  the  influence  of  medication,  until  the  exu- 
dation is  completed ;  then  there  is  a  lowering  of  the  tem- 
perature and  pulse,  and  relief  from  pain.  The  tempera- 
ture, however,  usually  remains  above  100°  or  101 '5°  F.  as 
a  rule. 

When  suppuration  begins,  there  is  a  renewal  of  the  symp- 
tomatic fever ;  sometimes  a  chill  precedes  this  recurrence  of 
fever.  On  the  other  hand,  if  resolution  takes  place,  the  fever 
does  not  return  to  any  very  great  extent.  During  the  sup- 
purative process,  until  the  time  when  the  pus  is  discharged, 
the  temperature  remains  usually  above  100°  F,,  sometimes 
suddenly  running  up  to  103°  F.,  indicating  that  there  may  be 
an  acute  septicaemia.     When  the  abscess  opens  and  is  com- 

14 


204  MEDICAL  GYNECOLOGY. 

pletely  emptied,  there  is  usually  a  prompt  and  almost  com- 
plete relief  from  the  symptomatic  fever. 

In  case  the  pus  remains  imprisoned  or  is  only  partially 
evacuated,  and  the  suppuration  and  discharge  continue  to  go 
on,  there  is  usually  marked  constitutional  disturbance,  mani- 
fested by  high  temperature  which  varies  abruptly  in  degree, 
at  times  running  down  almost  to  normal,  and  again  going  up 
to  104°  F.,  or  to  104-5°  F. 

In  other  words,  there  is  general  septicaemia  with  all  its 
constitutional  manifestations  instead  of  symptomatic  fever. 
This  is  really  a  secondary  septic  infection,  and  this  and  the 
evidence  of  suppuration  are  the  data  upon  which  one  can 
decide  that  the  medical  management  should  end  and  the 
surgical  begin. 

There  remains  to  be  mentioned  an  exceptional  form  of 
pelvic  inflammation  which  is  preceded  or  accompanied  by 
general  septicaemia.  In  that  condition  the  local  inflammation 
is  a  part  of  a  constitutional  affection.  There  is  in  that  con- 
dition septic  fever  as  well  as  symptomatic.  This  is  a  danger- 
ous condition  from  the  outset,  and  when  there  is  evidence  that 
the  source  of  infection,  say  in  the  uterus,  tubes,  or  peritonaeum, 
can  be  reached,  the  case  should  be  at  once  transferred  to  the 
surgeon. 

Physical  Signs. — In  the  early  stages  the  physical  signs 
are  few  and  of  limited  value.  Tenderness  and  tympanitic 
distention  of  the  lower  portion  of  the  abdomen  are  observed 
upon  palpation,  inspection,  and  percussion. 

The  location  of  the  tenderness  is  evidence  of  the  pelvic 
organ  or  tissue  affected.  General  acute  tenderness  is  present 
only  in  pelvic  peritonitis,  though  in  hysterical  women  it  may 
be  claimed  that  it  exists.  Tenderness  on  one  side  suggests 
that  the  inflammation  is  limited  to  that  side.  I  am  satisfied 
that  a  bimanual  examination  is  not  called  for  in  the  early 
stages  of  acute  pelvic  inflammation  :  first,  because  little  can 
be  discovered ;  and,  secondly,  such  examination  causes  pain 
and  aggravates  the  disease,  and  neither  patient  nor  physi- 
cian gains  any  advantage. 


ACUTE   INFLAMMATION  OF   THE   PELVIC   ORGANS.  205 

Causation. — There  are  certain  states,  no  doubt,  of  the 
general  organization  and  imperfections  in  the  sexual  organs 
which  predispose  to  chronic  inflammations,  but  I  do  not 
know  that  any  such  exist  in  relation  to  acute  disease. 

The  causes  are  septic,  specific,  and  traumatic.  Lymphan- 
gitis and  cellulitis  are  caused  by  sepsis  following  obstetric 
and  surgical  traumatisms.  Metritis  often  comes  from  the 
same  cause,  but  may  as  often  come  from  septic  and  specific 
infection.^  Salpingitis,  ovaritis,  and  pelvic  peritonitis  are,  as 
a  rule,  secondary  to  metritis  or  lymphangitis  of  a  septic  or 
specific  order. 

Treatment. — The  indications  are  to  arrest  or  modify  the 
inflammation,  to  relieve  suffering,  and  correct  the  derange- 
ments of  the  nutritive  and  nervous  systems  that  accompany 
or  are  caused  by  the  local  disease.  The  patient  should  first 
be  placed  in  the  most  comfortable  position  possible.  The 
back  is  preferred  by  most  patients.  Great  relief  is  given  in 
some  cases  by  elevating  the  foot  of  the  bed,  thereby  inclining 
the  body  toward  the  head.  Woolen  sheets  and  nightgowns 
are  preferable.  Heat  should  be  applied  to  the  extremities  if 
they  are  cold. 

The  means  employed  to  relieve  pain,  fortunately,  have  a 
beneficial  effect  upon  the  inflammation,  and  also  sustain  the 
nervous  system. 

Pain  should  be  relieved  and  kept  in  abeyance  by  the 
regular  administration  of  doses  of  opium  suflicient  to  accom- 
plish the  object.  When  it  is  possible,  opium  or  morphine 
should  be  given  by  the  mouth,  because  in  this  way  the 
patient  can  be  kept  more  uniformly  under  its  influence.  It 
often  happens,  however,  that  the  stomach  is  too  irritable  to 
retain  anything.  The  morphine  should  then  be  given  hypo- 
dermically  until  the  stomach  is  quiet.  In  some  cases  where 
there  is  marked  pelvic  tenesmus  the  opium  may  be  given  by 
the  rectum,  in  solution  by  enema,  because  if  administered  in 
suppositories  it  is  too  slowly  absorbed. 

Giving  the  opium  in  this  way  will,  as  a  rule,  relieve  the 
pelvic  tenesmus,  which  is  often  an  exceedingly  annoying 


206  MEDICAL  GYNECOLOGY. 

symptom.  In  many  cases  the  patient  has  a  constant  desire 
to  urinate,  but  all  efforts  to  do  so  only  increase  greatly  the 
suffering  ;  this  induces  the  patient  to  resist  the  desire,  so  that 
there  is  a  vesical  tenesmus  with  retention.  Under  these  cir- 
cumstances great  relief  can  be  given  by  the  careful  use  of  the 
catheter.  Warm  applications  may  be  made  to  the  abdomen 
in  the  form  of  fomentations.  Counter  irritation,  also,  is  often 
useful,  which  may  be  obtained  by  the  use  of  mustard  paste, 
turpentine  stupes,  or  capsicum  plaster. 

Sedatives,  and  warm  applications.  One  of  the  best  is 
absorbent  cotton  saturated  with  equal  parts  of  tincture  of 
belladonna  and  glycerin  applied  hot,  and  covered  with  rub- 
ber cloth.  The  old  flax-meal  poultice  is  objectionable,  owing 
to  its  weight. 

During  the  past  five  years  a  number  of  surgeons  have 
given  up  the  use  of  opium  in  the  treatment  of  pelvic  inflam- 
mation following  abdominal  operations,  and  that  has  led  phy- 
sicians to  be  timid  and  doubtful  in  the  management  of  the 
affections  now  under  consideration,  but  I  am  confident  that 
the  judicious  use  of  this  agent  saves  great  suffering,  and,  by 
quieting  irritation  and  sustaining  the  nervous  system,  favor- 
ably modifies  the  inflammatory  process. 

Ten  or  fifteen  grains  of  quinine  given  on  the  first  day 
of  the  inflammation  is  often  of  great  value  in  lessening  the 
fever  and  subduing  the  local  disease.  When  the  stomach  is 
irritable  it  can  be  given  in  solution  by  the  rectum. 

The  proper  management  of  the  digestive  organs — stomach 
and  intestines — is  highly  essential.  The  indications  are  two- 
fold :  flrst,  to  act  upon  the  local  disease  through  the  alimen- 
tary canal,  as,  for  example,  in  giving  saline  cathartics  to 
eliminate  septic  material  and  stimulate  the  portal  circula- 
tion ;  and,  secondly,  to  aid  nutrition  and,  by  sustaining  the 
patient,  enable  her  to  overcome  the  disease. 

The  stomach  is  always  upset  more  or  less.  In  some  there 
are  nausea,  loss  of  appetite,  and  thirst,  in  others  persistent 
vomiting  and  thii'st,  the  latter  condition  occurring  in  extreme 
form  when  the  peritonaeum  is  involved.     The  thii'st  should 


ACUTE  INFLAMMATION  OP  THE  PELVIC  ORGANS.  207 

be  relieved  by  small  doses  of  pure  or  sterilized  water.  It 
should  be  given  cold,  but  if  that  is  not  retained,  sips  of  hot 
water  should  be  given. 

Ice  allays  thirst  for  a  few  minutes,  and  patients  crave 
it  very  much,  but  it  does  harm  and  should  not  be  given. 
If  vomiting  continues,  all  iluid  by  the  mouth  must  be 
stopped  ;  and  an  enema  of  water  may  be  given  for  the  thirst 
as  often  as  necessary.  When  flatus  has  passed  freely  from 
the  bowels,  showing  that  the  intestinal  tract  is  free,  the 
quantity  of  fluid  may  be  increased. 

Many  things  have  been  used  to  quiet  the  stomach,  but 
until  the  local  irritation  subsides  and  the  bowels  act  there  is 
not  much  relief.  I  have  found,  when  hot  water  failed,  that 
a  cup  of  warm  tea  helped,  and  sometimes  aerated  waters  in 
small  doses.  In  some  desperate  cases  I  have  given  large 
draughts  of  water  and  had  the  patient  throw"  it  off — in  other 
words,  washed  out  the  stomach  in  that  way. 

When  the  stomach  is  irritable  and  the  patient  is  weak, 
whisky  can  be  added  to  the  water  used  in  the  enema,  and 
after  a  time  nutritive  enemata,  such  as  peptonized  foods,  or 
eggs  and  milk  with  brandy,  should  be  employed. 

No  solid  food  should  be  given  by  the  stomach  until  there 
is  a  desire  for  it  and  until  the  bowels  have  moved,  or  gas 
passed.  Then  the  diet  in  acute  disease,  commended  in  the 
chapter  on  diet,  should  be  employed.  Very  much  harm  is 
often  done  by  trying  to  give  food  by  the  mouth  when  the 
stomach  will  not  retain,  digest,  or  absorb  anything. 

The  management  of  the  intestines  must  proceed  simulta- 
neously with  the  treatment. 

In  all  acute  inflammation  of  the  pelvic  organs  the  old  way 
was  to  lock  up  the  bowels  ;  the  other  extreme  is  the  fashion 
of  the  present  day,  cathartics  being  used.  The  present  theory 
is  that  all  abdominal  and  pelvic  inflammations  are  septic,  and 
the  morbid  matter  can  be  eliminated  by  the  bowels.  Saline 
cathartics  are  therefore  used.  The  middle  course  is  the  cor- 
rect one,  I  am  sure. 

When  the  lower  intestine  is  loaded,   enemata  should  be 


208  MEDICAL  GYNECOLOaY. 

employed  to  empty  it.  I  prefer  three  ounces  of  sulphate  of 
magnesia,  and  two  ounces  each  of  glycerin  and  water,  to  be  re- 
peated until  the  desired  effect  is  produced.  After  this  I  use 
in  solution  small  doses  (half  a  drachm)  of  phos^Dhate  of  soda 
every  three  or  four  hours  if  the  stomach  will  retain  it. 
When  the  enema  does  not  give  relief  and  there  is  flatulent 
distention  (a  very  common  and  troublesome  condition),  atten- 
tion should  be  directed  to  its  relief.  There  are  two  causes 
which  give  rise  to  flatulence  that  can  and  should  be  differen- 
tiated clinically  :  one  a  local  paralysis  due  to  the  presence 
of  inflammation  ;  the  other  caused  by  general  paresis  from 
shock  of  the  sympathetic  nervous  system  in  general  septicae- 
mia. In  the  former  there  is  peristaltic  action  of  the  upper 
part  of  the  intestine  and  colicky  pain,  and  in  the  latter  there 
is  complete  inaction  of  the  intestine  and  continuous  pain. 

In  general  paresis  due  to  exhaustion  of  the  sympathetic 
ganglia  I  use  the  following  mixture  of  Keith :  ^  Magnes. 
sulph.,  3j;  magnes.  carb.,  gr.  x;  aq.  menth.  pip.,  ^ss. ;  aq. 
ad  §  ij.  Sig.  :  The  dose  to  be  repeated  every  two  hours  until 
the  bowels  move.  If  the  stomach  will  not  retain  this,  or  if 
it  does  not  act,  I  use  another  agent  employed  by  the  Keiths. 
Six  grains  of  sulphate  of  quinine  dissolved  in  two  drachms 
of  whisky  in  a  couple  of  ounces  of  warm  water  are  to  be  in- 
jected into  the  bowel,  and  repeated  every  two  hours  until 
three  doses  have  been  given,  and  set  up  peristaltic  action. 

In  the  first-described  condition,  in  which  there  are  fre- 
quent colicky  pains  showing  the  existence  of  peristaltic  ac- 
tion and  no  appearance  of  the  flatus  passing  downward,  ten 
drops  of  liq.  opii  comp.  and  five  drops  of  tincture  of  bella- 
donna in  a  little  hot  water  are  instilled  into  the  rectum,  and 
repeated  until  the  pain  is  relieved.  After  a  rest  of  three  or 
four  hours,  the  quinine  by  the  rectum  should  be  given  and 
repeated  if  need  be. 

The  next  object  in  the  treatment  is  to  favor  a  further  limi- 
tation of  the  plastic  exudation,  and  to  promote  the  absorp- 
tion of  the  inflammatory  products  ;  this  can  be  accomplished, 
if  at  all,  by  the  use  of  counter-irritation.     When  all  acute 


ACUTE  INFLAMMATION  OF  THE  PELVIC  ORGANS.  209 

symptoms  have  subsided  and  there  is  no  evidence  of  any 
serum  or  pus  accumulated  in  the  pelvis,  the  further  dispo- 
sition of  the  inflammatory  products  may  be  favored  by  the 
following  treatment :  Small  blisters  applied  in  the  iliac 
region,  and  repeated,  often  give  the  patient  relief  from  dis- 
turbance, and  apparently  favor  the  absorption  of  the  inflam- 
matory products.  The  best  method  of  employing  blisters 
under  these  circumstances  is  to  apply  two,  one  on  each  side, 
to  be  kept  there  until  the  skin  is  thoroughly  vesicated,  then 
puncture'  the  vesicle  and  let  out  all  the  serum  and  allow  the 
cuticle  to  fall  down  upon  the  cutis,  and  then  apply  over  this 
absorbent  cotton,  and  allow  it  to  remain  undisturbed  until 
healing  is  complete,  which  usually  takes  place  in  from  two  to 
four  days  ;  blisters  may  again  be  applied  in  the  same  way. 
During  this  time  the  patient  should  be  sustained  by  nourish- 
ment and  tonics,  quinine  being  one  of  the  most  reliable 
agents.  The  tincture  of  iodine  may  be  applied  through  the 
speculum  to  the  roof  of  the  pelvis — that  is,  around  the  cervix 
uteri  and  upper  part  of  the  vagina — and  iodide  of  iron  may  be 
given  internally.  Counter  irritants  from  time  to  time  should 
be  continued.  One  part  of  croton  oil  dissolved  in  two  parts  of 
sulphuric  ether,  to  which  are  added  three  parts  of  tincture 
of  iodine,  makes  a  good  application  for  keeping  up  continu- 
ous irritation  ;  this  should  be  painted  over  the  lower  portion 
of  the  abdomen,  and  repeated  when  the  fine  eruption  which 
it  produces  has  disappeared. 

These  remedies  should  be  changed  after  a  time  to  the 
iodide  of  potassium  or  the  bichloride  of  mercury  with  chlo- 
ride of  iron,  the  latter  being  the  most  valuable  as  a  tonic  and 
alterative.  While  there  are  still  some  of  the  products  of 
inflammation  remaining  in  the  pelvis,  or  at  least  for  a  long 
time  after  the  subsidence  of  the  acute  inflammatory  symp- 
toms, the  greatest  possible  care  should  be  taken  to  guard  the 
patient  against  undue  exercise  ;  standing,  walking,  or  riding 
may  produce  a  relapse,  and  hence  the  patient  should  be 
made  to  carefully  feel  her  way  in  sitting  up  and  in  taking 
exercise  ;  especially  should  this  care  be  insisted  upon  at  the 


210  MEDICAL  GYNECOLOGY. 

menstrual  periods.  No  rales  can  be  laid  down  with  refer- 
ence to  this,  except  that  any  exercise  which  excites  pain 
should  be  avoided  ;  short  stages  of  exercise,  followed  by 
rest  in  the  recumbent  position,  should  be  adhered  to,  a 
little  more  liberty  being  given  every  day,  in  case  it  does  not 
produce  pain.  To  promote  absorption  and  loosen  adhesions, 
massage,  as  practiced  by  Brandt  and  described  in  the  part 
of  this  work  on  general  therapeutics,  may  be  tried. 


CHAPTER  XVIII. 

CHEpNIC   INFLAMMATIOISr   OF  THE  PELVIC   OEGAN^S. 

Metritis. — Metritis  occurs  in  a  variety  of  forms,  and  on  that 
account  there  are  many  classifications  of  this  affection.  Con- 
sidering the  subject  from  a  medical  standpoint,  I  am  sure  that 
the  following  arrangement  will  answer  my  present  purpose  : 

Classified  according  to  the  duration  and  intensity  or  de- 
gree of  inflammation,  there  are  acute  and  chronic  metritis ; 
according  to  causation,  catarrhal,  septic,  and  specific  ;  accord- 
ing to  the  tissues  involved,  cervical  and  corporeal  endometri- 
tis and  general  metritis. 

Aciite  metritis  is  rare  except  when  caused  by  septic  or 
specific  infection. 

General  metritis,  in  which  all  the  tissues  of  the  uterus  are 
involved,  is  seldom  seen  except  in  the  puerperal  state  and  in 
neoplasms  of  the  uterus.  The  acute,  septic,  specific,  and  puer- 
peral forms  have  been  referred  to  in  the  preceding  chapter 
on  acute  inflammatory  affections  of  the  pelvic  organs. 

The  catarrhal,  non-specific  form  of  metritis — cervical  and 
corporeal — is  that  which  naturally  comes  in  for  the  largest 
share  of  the  physician's  attention,  and.  hence  the  present 
remarks  will  be  limited  to  this  part  of  the  subject.  It 
should  be  said,  however,  that  the  medical  treatment  of  ca- 
tarrhal metritis  applies  in  other  forms  which  require  surgi- 
cal treatment  as  well  to  a  limited  extent. 

Chronic  Endometritis. — One  would  naturally  suppose  that  in 
endometritis  the  inflammatory  process,  when  once  begun  at 
any  part  of  the  mucous  membrane,  would  extend  to  the  whole 
endometrium,  but  such  is  not  the  case.     Clinical  observations 

211  . 


212  MEDICAL  GYNECOLOGY. 

show  that  cervical  endometritis  frequently  occurs  without 
corporeal.  They  occur  together  also,  but  cervical  endome- 
tritis is  most  frequently  found.  This  law  in  the  pathology  of 
uterine  disease,  which  appears  peculiar,  is  explained  possibly 
by  the  fact  that  the  mucous  membrane  in  its  anatomical 
structure,  and  more  especially  in  its  function,  differs  very 
widely  in  the  body  and  cervix  uteri.  Certain  it  is  that  the 
pathology  and  symptomatology,  as  well  as  the  physical  signs, 
show  that  corporeal  and  cervical  endometritis  are  two  very 
distinct  affections,  demanding  different  consideration  and 
treatment. 

At  the  same  time  I  must  admit  that  they  have  many  fea- 
tures in  common,  and  that  they  also  occasionally  occur  to- 
gether, hence  I  shall  give  some  general  remarks  which  will 
apply  to  both. 

There  has  been  much  discussion  regarding  the  pathology 
of  endometritis,  both  cervical  and  corporeal.  Much  of  this 
difference  of  opinion  arises,  I  think,  from  the  use  of  the  terms. 
Some  claim  that  the  only  lesion  in  this  affection  is  conges- 
tion ;  others  hold  that  there  is  true  inflammation,  the  differ- 
ence apparently  arising  from  the  fact  that  one  defines  inflam- 
mation as  one  thing,  while  another  believes  it  to  be  something 
else. 

If  endometritis,  as  it  is  usually  seen  in  practice,  is  com- 
pared with  the  process  of  inflammation  in  other  mucous  mem- 
branes when  it  runs  its  entire  course,  then  it  will  be  found 
that  endometritis  is  exceptional.  It  is  known  that  in  ordi- 
nary inflammation  of  the  mucous  membranes  there  is  first  con- 
gestion, then  hypersecretion,  then  suppuration  or  purulent 
secretion,  occasionally  ulceration,  and  rarely — if  ever — except 
in  specific  inflammation,  an  exudation  of  plastic  lymph  ;  then 
recovery  follows. 

The  damage  done  to  the  membranes  depends  upon  whether 
the  process  ends  in  suppuration,  ulceration,  or  exudation.  If 
this  is  taken  as  the  typical  result  of  inflammation  of  mucous 
membranes,  then  it  is  true  that  inflammation  of  the  mucous 
membrane  of  the  uterus  is  extremely  rare ;  but  the  fact  is 


CHRONIC  INFLAMMATION"  OP  THE  PELVIC  ORGANS,        213 

that  the  process  of  inflammation  in  mucous  membranes  may 
go  on  to  congestion  and  hypersecretion  and  stay  there.  If 
these  are  long  continued,  certain  changes  in  the  mucous 
glands,  epithelium,  and  cellular  tissue  take  place ;  but  sup- 
puration or  ulceration  does  not  occur,  as  a  rule,  in  endome- 
tritis. 

The  inflammatory  process  does  not  begin,  run  through  all 
its  stages,  and  then  end  ;  but  it  begins  and  progresses  to  a 
given  stage,  and  is  continuous  instead  of  ending  at  a  definite 
time. 

Pathology.— hi  cervical  endometritis,  which  is  now  usually 
called  uterine  catarrh,  there  is  very  decided  congestion  and 
hypersecretion  of  the  glands  of  the  cervix.  This  secretion 
differs  very  little  in  its  physical  properties  from  that  which  is 
normal,  except  that  it  is  excessive  in  quantity.  If  this  con- 
gestion is  long  continued,  the  exfoliation  of  epithelium  pro- 
gresses faster  than  its  replacement  by  the  development  of 
new  cells,  so  that  the  membrane  is  covered  with  young  epithe- 
lium, which  gives  it  a  reddish  color. 

This  disturbance  of  the  balance  between  the  process  of 
exfoliation  and  reproduction  not  only  involves  the  mucous 
membrane  of  the  canal,  but  extends  outward  from  the  os  ex- 
ternum about  half  the  thickness  of  the  walls  of  the  cervix. 
This  gives  rise  to  the  conditions  which  were  described  by  the 
older  writers  as  ulceration  of  the  cervix  uteri. 

These  are  the  principal  anatomical  changes  found  in  this 
form  of  endometritis  which  come  under  the  notice  of  the 
physician. 

There  are  other  changes  which  appear  in  septic,  specific, 
and  traumatic  endometritis,  which  will  now  be  given,  as  they 
are  guides  in  determining  the  cause,  and  indicate  that  sur- 
gical treatment  is  necessary. 

As  the  process  advances,  the  mucous  membrane  becomes 
thickened  by  proliferation  of  the  areolar  tissue  and  by  dis- 
tention of  the  blood-vessels,  so  that  it  becomes  too  large  for 
the  surface  which  it  covers ;  this  throws  it  into  the  fine 
rugosities  or  wrinkles  which  give  the  surface  a  granular  or 


214  MEDICAL   GYNECOLOGY. 

papillous  appearance.  These  projecting  points  were  sup- 
posed by  the  older  pathologists  to  be  an  enlargement  of  the 
papillae  of  the  mucous  membrane,  but  it  is  now  known  that 
they  are  new  formations  due  to  areolar  hyperplasia.  It  is 
supposed  also  that  the  glands  undergo  some  pathological 
change  other  than  mere  congestion,  but  probably  the  only 
change  is  a  congestion  and  modification  of  the  epithelium 
which  lines  them. 

It  is  claimed  by  some  that  new  glands  are  developed 
upon  the  outer  surface  of  the  cervix  around  the  os  externum. 
I  am  inclined  to  think,  however,  that  the  glands  which  are 
seen  outside  of  the  os  externum  in  cervical  endometritis  ap- 
pear there  because  of  the  thickening  of  the  mucous  membrane, 
which  causes  inversion  or  prolapsus  of  this  membrane. 

It  is  difficult  to  believe  that  the  inflammatory  process 
could  lead  to  the  development  of  new  anatomical  structures 
of  a  normal  character,  but  there  is  strong  evidence  to  show 
that  this  occurs  in  the  mucous  membrane  of  the  cervix 
uteri. 

Sometimes  the  irregularity  of  surface  due  to  hyperplasia 
is  very  marked,  especially  in  cases  where  there  is  laceration 
of  the  cervix.  This  condition  has  been  called  ' '  granular  de- 
generation " — a  good  enough  name,  if  it  is  remembered  that 
it  is  produced  by  a  throwing  up  of  the  membrane  into  folds 
or  projections  by  an  enlargement  and  thickening  due  to  hy- 
perplasia, and  that  it  is  not  a  degeneration  in  fact. 

In  some  cases,  especially  those  that  have  been  treated 
with  caustics,  the  mouths  of  the  ISTabothian  glands  are 
closed,  and  the  glands  become  distended  by  their  secretion 
and  form  cystlike  bodies  deep  in  the  membrane.  These  are 
usually  seen  at  the  surface  as  whitish,  pearly-looking  points, 
which  contrast  with  the  deep-red  color  of  the  mucous  mem- 
brane around  them.  To  the  touch  they  feel  like  shot  im- 
bedded in  the  membrane.  These  have  long  been  known  as 
the  "ovulae  N'abothii."  More  recently  this  condition  has 
been  called  "cystic  degeneration  of  the  cervix."  Sometimes 
one  or  more  of  them  become  very  large,  and  by  pressure 


CHRONIC  INFLAMMATION   OF  THE   PELVIC   ORGANS.        215 

cause  absorption  of  the  middle  wall  of  the  uterus  around 
them. 

The  hypersemia  sometimes  extends  to  the  middle  coat  of 
the  cervix,  and  then  for  a  time  the  tissues  are  softened  and 
oedematous.  With  this  condition  there  is  usually  free  leu- 
corrhcea  and  menorrhagia,  especially  when  the  body  of  the 
uterus  is  affected.  Occasionally,  though  rarely,  the  men- 
strual flow  is  suspended  or  diminished.  In  some  cases  of 
long  standing  when  there  is  laceration  of  the  cervix,  the 
areolar  hyperplasia  extends  to  all  the  tissues  of  the  cervix, 
giving  rise  to  that  induration  known  as  sclerosis. 

The  pathology  of  chronic  corporeal  endometritis  is  the 
same  in  the  early  stages  as  in  cervical.  In  the  more  ad- 
vanced stages  the  structural  changes  differ  slightly.  In  the 
corporeal  the  most  important  change  is  hyperplasia  of  the 
epithelium  and  cellular  tissue  around  the  mouths  of  the 
utricular  glands.  This  new  formation  is  of  a  polypoid  char- 
acter, and  has  been  designated  by  the  terms  endometritis 
polyposa  or  fungosities.  In  all  other  respects — such  as  de- 
ranged innervation,  congestion,  degeneration  of  the  epithe- 
lium, and  exfoliation  and  hypersecretion — the  chronic  cor- 
poreal and  cervical  inflammations  are  alike.  The  character 
of  the  discharge  differs,  but  this  will  be  noticed  in  speaking 
of  the  symptoms. 

Symptomatology. — Cervical  endometritis  does  not  neces- 
sarily give  rise  to  marked  constitutional  disturbance ;  when 
it  does  so,  the  symptoms  usually  appear  in  the  form  of  gen- 
eral debility,  especially  of  the  nervous  system.  The  patient 
may  become  easily  fatigued  and  somewhat  changed  in  dis- 
position, and  less  inclined  to  mental  activity.  Sometimes 
there  is  considerable  mental  disturbance,  but  much  of  all  this 
is  usually  due  to  the  fact  that  the  patient  is  annoyed  by  the 
presence  of  a  more  or  less  profuse  leucorrhoea,  which  gives 
her  discomfort  and  leads  her  to  suppose  that  she  is  suffering 
from  a  serious  affection.  The  constitutional  effects  of  this 
local  affection  depend  very  much  upon  the  sensitiveness  of 
the  patient. 


216  MEDICAL   GYNECOLOGY. 

The  menstrual  function  is  not  necessarily  affected.  In 
cases  of  long  standing  there  may  be  irregular  menstruation, 
and  the  flow  may  be  diminished,  but  this  is  not  the  rule. 

The  character  of  the  leucorrhoeal  discharge  is  diagnostic. 
It  is  dense,  thick,  opaque,  and  tenacious,  while  the  vaginal 
leucorrhcea  is  serous,  non-tenacious,  and  sometimes  slightly 
purulent.  If  the  disease  is  long  continued,  backache  comes 
on,  the  pain  being  located  in  the  sacral  region,  which  distin- 
guishes it  from  the  lumbar  pain  characteristic  of  general  de- 
bility and  some  of  the  acute  diseases.  There  is  often  some 
pelvic  tenesmus.  All  these  symptoms  are  usually  very  much 
aggravated  by  muscular  exercise,  and  at  each  menstrual 
period.  They  are  present  in  cervical  and  corporeal  metri- 
tis, but  in  the  corporeal  form  there  are  additional  special 
symptoms  which  should  be  well  observed.  The  digestive 
organs  are  more  deranged — that  is,  there  are  far  more  reflex 
gastric  derangements  in  corporeal  metritis.  The  bowels  are 
also  more  often  constipated.  The  nervous  system,  especially 
the  sympathetic,  is  more  often  depressed  and  exhausted. 
Most  important  of  all,  the  menstrual  function  is  affected  to 
an  extent  never  known  where  the  cervix  alone  is  involved. 
As  a  rule  there  is  menorrhagia.  The  menses  are  profuse 
and  prolonged,  sometimes  irregular ;  sometimes,  and  mostly 
in  cases  of  long  standing,  there  may  be  amenorrhoea  or 
scanty  menstruation.  These  points  are  symptomatic  of  cor- 
poreal endometritis,  and  the  practitioner  has  to  depend  upon 
them  in  making  a  diagnosis. 

These  symptoms  and  the  history  generally  are  sufficient 
to  guide  the  physician  in  instituting  treatment,  which,  if  not 
efficient  after  a  fair  trial,  shows  that  surgical  measures  should 
be  resorted  to.  At  least  a  local  examination  is  necessary  in 
order  to  determine  the  exact  nature  of  the  case. 

Causation. — The  predisposing  causes  of  endometritis  are 
imperfections  in  the  general  organization  and  in  the  develop- 
ment and  growth  of  the  sexual  organs,  scrofulous  and  tuber- 
cular diatheses.  The  exciting  causes  of  cervical  endometritis 
are  vaginitis  and  injuries  of   the  cervix.      Imperfect  men- 


CHRONIC  INFLAMMATION  OF   THE   PELVIC   ORGANS.        217 

strual  involution  and  derangements  of  menstruation  cause 
the  corporeal  variety. 

Defects  in  the  development  and  growth  of  the  sexual 
organs  are  the  chief  predisposing  causes  of  this  variety  of 
endometritis.  General  ill  health  is  also  a  cause.  Scrofulous 
and  tubercular  diatheses  invite  chronic  inflammation  of  the 
mucous  membranes  generally,  and  the  membrane  of  the 
uterus  is  no  exception. 

When  the  uterus  is  under  size  or  malformed  in  a  slight 
degree,  so'  that  menstruation  is  imperfectly  performed,  an  in- 
flammation of  its  mucous  membrane  is  very  likely  to  come  on 
sooner  or  later.  Sedentary  habits  and  unsuitable  clothing, 
overfatigue  in  standing  or  walking,  or  anything  which  inter- 
rupts the  return  circulation  from  the  pelvis,  predisposes  to 
this  affection.  Using  the  sewing  machine  was  the  great  tUe 
noir  of  the  gynecologist  years  ago.  Now,  I  presume,  bicy- 
cling and  type-writing  should  come  in  with  the  sewing  ma- 
chine for  their  share  of  abuse.  So,  also,  deranged  nutrition, 
from  insuflicient  nutriment  or  overtaxation,  mental  or  phys- 
ical, which  lead  to  impoverishment  of  the  blood.  Frequent 
child-bearing  and  prolonged  lactation  also  predispose  to  the 
same  trouble.  All  these  causes  act  to  produce  derangement 
of  innervation  and  circulation,  and  so  favor  the  development 
of  chronic  inflammation. 

The  exciting  cause  which  plays  the  most  important  part 
in  endometritis  is  imperfect  involution  after  confinement  or 
menstruation.  The  great  majority  of  cases  take  their  origin 
from  this  imperfection  of  the  menstrual  or  parturient  involu- 
tion. 

Other  exciting  causes  which  may  be  mentioned  are  in- 
juries to  the  uterus  from  displacements  ;  the  use  of  ill-fitting 
pessaries  ;  injuries  during  confinement,  causing  puerperal  in- 
flammations ;  abortion,  especially  if  produced ;  intemperate 
coition  ;  sexual  starvation ;  and  efforts  to  prevent  conception. 
So  far  as  I  know,  the  same  causes  produce  both  cervical  and 
corporeal  endometritis,  so  that  in  the  present  state  of  our 
knowledge  I  am  not  prepared  to  state  any  difference  in  the 


218  MEDICAL  GYNECOLOaY. 

causes  of  the  two  affections,  if  any  such  exists.  I  am  in- 
clined to  think,  however,  that  as  cervical  endometritis  is  be- 
yond doubt  much  more  common  than  corporeal,  it  may  be 
inferred  that  the  one  tends  to  the  development  of  the  other. 

Treatment. — The  prevailing  opinion  at  this  time  is,  that 
endometritis  can  only  be  relieved  by  local  treatment.  That 
is  true  of  certain  forms  of  the  affection,  but  catarrhal  endome- 
tritis, if  seen  early,  can  be  cured  by  general  medical  treatment 
and  the  vaginal  douche.  This  I  know  from  having  seen  a 
number  of  unmarried  women  who  had  all  the  history  of  en- 
dometritis, cervical  and  corporeal,  and  recovered  under  medi- 
cal treatment.  More  than  that,  I  have  examined,  under  an 
anaesthetic,  young  patients  and  found  endometritis  of  the 
variety  now  under  discussion,  and  they  also  have  recovered 
nnder  general  treatment.  Now,  while  constitutional  and 
local  treatment — i.  e.,  medical  and  surgical — are  necessary 
in  the  majority  of  cases,  there  are  cases  that  can  be  man- 
aged by  the  physician.  Moreover,  the  surgeon  finds  that 
most  cases  require  constitutional  treatment,  hence  the  medi- 
cal side  of  the  subject  should  be  fully  considered.  At  the 
present  time  the  medical  has  to  give  way  to  the  surgical 
treatment  to  an  unreasonable  degree,  therefore  I  shall  in  this 
connection  fully  discuss  the  general  medical  treatment — 
chronic  form — of  all  the  inflammatory  affections  of  the  sex- 
ual organs. 

The  special  treatment  of  endometritis  consists  in  first  re- 
moving the  cause  whenever  that  is  possible,  regulating  the 
rest,  exercise,  and  diet,  and  the  use  of  the  hot- water  douche. 
The  diet  is  of  much  importance.  Those  who  are  exhausted 
and  ansemic  require  the  restorative  diet  and  medication  fully 
discussed  further  on.  Others  of  full  habit  require  spare  diet, 
and  little  if  any  animal  food. 

Certain  medicinal  agents  that  act  directly  upon  the  sexual 
organs  may  be  employed  with  advantage  in  metritis.  In  cor- 
poreal endometritis  attended  with  profuse  menstruation,  hy- 
drastis  canadensis  and  ergot  are  useful.  I  prefer  to  nse  the 
former,  but  in  obstinate  cases  both  may  be  employed ;  the 


CHRONIC  INFLAMMATION  OP  THE   PELVIC   ORGANS,        219 

ergot  should  be  used  in  small  doses.  The  effect  of  the  hy- 
drastis  is  remarkable  in  contracting  the  blood-vessels  and 
lessening  the  congestion.  When  the  leucorrhoeal  discharge  is 
the  chief  symptom,  alteratives  are  indicated.  Iodine  and 
mercury  are  most  efficient.  When  the  general  health  is  good 
and  the  patient  stout,  iodide  of  soda  in  medium  doses  is 
beneficial.  Anaemic  weak  patients  should  take  iodide  of 
iron.  This  is  most  useful  in  those  of  the  strumous  diathe- 
sis and  phlegmatic  temperament. 

Mercury  has  been  employed  for  its  alterative  effects  upon 
the  endometrium.  I  believe,  however,  that  it  has  no  advan- 
tage over  iodine  excepting  in  certain  cases  of  endometritis 
with  hyperplastic  growths  of  the  mucous  membrane.  In 
such  cases  the  continued  use  of  small  doses  of  bichloride  of 
mercury  combined  with  iron,  quinine,  or  arsenic,  as  may  be 
indicated  in  given  cases,  is  of  much  value.  Arsenic  is  very 
efficient  in  endometritis  complicated  with  malaria  or  mal- 
nutrition of  the  skin  and  mucous  membranes. 

For  a  discussion  of  this  subject  the  reader  is  referred  to 
the  chapter  on  the  management  of  the  nutritive  and  nerv- 
ous systems  and  their  derangements  as  found  associated 
with  inflammatory  diseases  of  the  sexual  organs.  This  may 
be  called  the  constitutional  or  indirect  treatment  of  local 
diseases. 


15 


CHAPTER  XIX. 

CHEOlSriC   IISTFLAMMATIOX    OF   THE  PELVIC   OKGAISTS. 

{Continued.^ 

OHRONIO   OVARITIS   AND   SALPINGITIS. 

Inflammation  of  the  Ovaries.— There  are  two  forms  of  inflam- 
mation of  the  ovaries,  the  acute  and  the  chronic.  These  are 
distinctly  different  so  far  as  their  clinical  history  is  con- 
cerned. There  is  another  affection  closely  allied  to  these 
which  is  described  by  some  writers  as  hypersemia.  Acute 
ovaritis  I  have  classed  with  acute  pelvic  inflammations. 
That  leaves  for  present  consideration  the  chronic  form  of  in- 
flammation and  hypersemia  of  the  ovaries. 

Ovarian  Hypersemia. — While  many  of  the  characteristics  of 
ovarian  hypersemia  are  like  those  of  ovaritis,  there  is  very 
good  reason,  based  upon  clinical  evidence,  to  believe  that  the 
two  are  different  both  in  pathology  and  clinical  history. 

Ovarian  hypersemia,  as  it  is  generally  observed,  resembles 
many  of  the  so-called  functional  diseases,  in  that  there  is 
derangement  of  function,  which  usually  disappears,  leaving 
no  evidence  that  there  has  ever  been  any  change  of  structure 
or  products  of  inflammation.  This  indicates  that  the  pathol- 
ogy is,  as  the  name  implies,  a  congestion,  and  the  consequent 
derangement  of  function  with  the  accompanying  or  resulting 
pain  and  suffering.  The  hypersemia  usually  affects  both 
ovaries,  and  as  a  rule  extends  to  the  uterus,  giving  rise  to 
derangement  of  menstruation.  The  congestion  and  func- 
tional derangements  of  the  uterus  may  be  secondary  to  or 
precede  the  ovarian  hypersemia.  There  is  much  in  regard  to 
pathology  of  this  affection  which  is  inferred  from  the  symp- 

230 


CHRONIC  INFLAMMATION  OF  THE  PELVIC  ORGANS.        221 

toms,  and  can  not  be  demonstrated.  The  congestion  may  be 
of  long  or  of  short  duration,  its  continuance  depending  upon 
the  persistence  of  the  causes  which  give  rise  to  it.  When 
long-continued,  it  tends  to  chronic  ovaritis  and  to  degen- 
eration of  the  ovaries  and  premature  atrophy.  Should  the 
causes  which  produce  the  congestion  continue  active  and  no 
treatment  be  employed,  the  affection  may  continue  indefi- 
nitely. The  general  health  becomes  undermined  by  the  de- 
rangement of  the  menstrual  function  and  the  exhaustion  of 
the  nervous  system ;  and  if  the  patient  is  not  relieved  by 
treatment  or  by  improved  hygienic  conditions,  she  continues 
a  sufferer  until  the  menopause. 

With  so  little  that  is  definite  regarding  the  pathology, 
one  might  well  ask  if  the  fact  is  yet  established  that  there 
is  a  distinct  affection  to  be  known  as  ovarian  hypersemia. 
In  answer  to  this,  it  can  only  be  said  that  the  clinical  his- 
tory points  to  a  lesion  of  the  circulation  as  the  only  rational 
explanation  of  the  phenomena  presented  in  these  cases. 
There  necessarily  must  be  present  in  this  affection  a  de- 
rangement of  ovarian  innervation  which  is  the  starting  point 
of  this  affection.  This  view  of  the  matter  is  favored  by  the 
fact  of  the  affection  depending  for  its  origin  upon  perversion 
of  the  emotions  in  those  of  nervous  temperament. 

Symptomatology.  — Hypersemia  of  the  ovaries  occurs  most 
frequently  among  those  who  are  unmarried,  or  among  young 
widows  who  have  never  had  children. 

It  does  not  come  on  abruptly,  like  an  attack  of  acute 
ovaritis,  though  it  occasionally  does  so,  but  is  developed 
rather  gradually.  Those  most  liable  to  this  affection  are  the 
nervous  and  emotional  who  live  in  conditions  of  life  favoring 
excitation  without  complete  functional  action  of  the  sexual 
organs.  I  have  never  seen  a  case  of  this  kind  among  those 
who  lived  under  wholesome  conditions  of  life  or  who  were 
married,  bearing  and  nursing  children,  and  who  lived  quiet, 
rational  lives.  At  the  beginning  there  are  pain  and  heaviness 
in  the  region  of  the  ovaries,  usually  accompanied  by  much 
nervous  irritability  and  weakness,   the  patient  being  easily 


222  MEDICAL  GYNECOLOGY. 

excited  and  as  easily  fatigued.  The  pain  in  the  ovaries  in- 
creases four  or  six  days  before  the  menstrual  period.  This  is 
due  to  ovulation,  and  I  have  long  been  in  the  habit  of  call- 
ing it  painful  ovulation.  Soon  after  the  appearance  of  these 
symptoms  the  menstrual  function  becomes  deranged.  There 
is  usually  menorrhagia.  Sometimes  the  pain  is  relieved  and 
the  patient  feels  much  better  during  the  menstrual  flow,  and 
for  a  time  after  it  ceases.  In  some  cases  the  first  symptom 
developed  is  menorrhagia.  The  free  menstrual  flow  is  con- 
servative at  first,  relieving  the  congestion  which  produced  it. 
I  have  frequently  seen  young  women,  who  apparently  suf- 
fered from  ovarian  congestion,  recover  completely  after  one 
or  more  free  attacks  of  menorrhagia.  When  the  excessive 
menstruation  does  not  relieve  the  congestion,  which  it  may 
not  do  if  the  causes  which  produced  it  are  continued,  it 
leads  to  anaemia  and  nerve  exhaustion,  and  this  state  of 
health  may  continue  indefinitely. 

There  are  other  symptoms  which  may  be  mentioned,  as 
backache  and  general  pelvic  tenesmus,  increased  on  walking 
sometimes,  but  not  always.  In  the  less  severe  forms  of 
hypersemia  of  not  very  long  standing,  muscular  exercise 
gives  relief,  not  for  the  time  only,  but  is  oftentimes  perma- 
nently beneficial.  There  is  often  irritability  of  the  bladder, 
which  is  purely  nervous. 

Physical  Signs. — There  is  tenderness  on  deep  pressure 
made  in  the  iliac  regions,  not  acute,  but  of  that  dull  charac- 
ter which  is  peculiar  to  the  ovaries.  As  the  disease  affects 
both  ovaries,  as  a  rule,  there  is  tenderness  alike  on  both 
sides. 

Bimanual  examination  usually  shows  tenderness  better 
than  abdominal  pressure,  but  I  have  found  that  in  these 
cases  it  is  very  difficult  to  grasp  the  ovaries  between  the  two 
hands,  owing  to  the  fact  that  the  abdominal  muscles  are 
tense  ;  while  in  the  majority  of  cases  there  is  tenderness  if 
pressure  is  made  upon  the  ovaries,  either  through  the  vaginal 
or  abdominal  walls,  I  have  seen  many  cases  in  which  steady 
but  not  too  heavy  pressure  in  the  iliac  regions  gave  relief. 


CHRONIC   INFLAMMATION  OF  THE   PELVIC   ORGANS.        223 

Perhaps  these  were  cases  of  the  kiad  that  Charcot  calls 
hystero-epilepsy,  in  which  the  convulsions  are  relieved  by- 
pressure  upon  the  ovaries.  I  have  seen  some  of  Charcot's 
that  appeared  to  be  due  to  ovarian  hypersemia. 

The  physical  signs  obtained  are  rather  negative,  but  by 
excluding  the  evidence  of  other  ovarian  affections,  and  tak- 
ing the  history  into  account,  a  presumptive  diagnosis  can  be 
made,  and  the  diagnosis  will  be  confirmed  by  the  subsequent 
history.  Under  treatment  and  improved  moral  and  physical 
hygiene,  recovery  will  take  place  much  more  promptly  and 
completely  than  in  chronic  inflammation. 

In  connection  with  this  affection  of  the  ovaries,  especially 
if  it  has  existed  for  several  months,  there  is  usually  con- 
gestion of  the  uterus  and  vagina  which  yields  promptly  to 
medical  treatment. 

Prognosis. — The  great  majority  of  patients  recover  under 
appropriate  treatment.  In  fact,  many  of  them  recover  after 
the  causes  are  removed  without  any  treatment  whatever. 

Causation. — Overstimulation  of  the  emotions  in  those  of 
a  nervous  temperament  is  one  of  the  chief  causes  of  ovarian 
congestion.  This  is  operative  among  those  who  are  not  use- 
fully employed,  but  permitted  or  even  encouraged  to  turn 
their  attention  to  the  procreative  function  while  they  are 
still  undergoing  development.  Stimulating  tonics  which 
create  an  appetite  which  is  not  satisfied  with  food  will  cause 
gastric  congestion,  and  all  the  consequences  which  arise 
therefrom.  In  like  manner  stimulating  the  sexual  appetence 
of  unoccupied  emotional  young  girls  by  evil  influences  or  im- 
proper associations  leads  to  ovarian  congestion.  Those  who 
have  lived  in  the  proper  exercise  of  the  sexual  function,  but 
have  been  abruptly  cut  off  from  normal  gratification,  are 
prone  to  ovarian  congestion.  Indulgence  beyond  normal 
gratification  is  also  said  to  have  produced  the  same  result. 
All  these  causes  are  to  a  great  extent  psychical,  but  ovarian 
congestion  may  be  produced  by  purely  physical  causes.  It 
may  be  secondary  to  endometritis,  sedentary  habits,  tight 
clothing,  and  constipation,  which  may  interrupt  the  free  cir- 


224  MEDICAL  GYXECOLOGY. 

culation  in  the  pelvic  organs.  It  is  rare,  however,  that  cases 
of  ovarian  congestion  can  be  traced  to  such  causes. 

Treatment. — The  removal  of  the  cause,  when  that  can  be 
accomplished,  is,  as  I  have  already  said,  often  sufficient  to 
give  relief.  The  termination  of  an  engagement  in  marriage 
has  cured  the  monorrhagia  in  many  cases,  and  complete  re- 
covery has  followed  when  pregnancy  occurred. 

A  like  benefit  has  been  brought  about  in  younger  pa- 
tients by  directing  the  attention  to  something  other  than 
self  and  the  feelings  and  emotions.  A  change  from  books 
and  society  to  the  woods  and  fields,  and  outdoor  occupa- 
tion in  the  way  of  amusements,  should  be  employed.  Bath- 
ing is  useful — either  sea  bathing  or  the  shower  bath — if  the 
patient  is  strong  enough  to  bear  it.  Tonics  to  restore  the 
general  strength,  nux  vomica  being  the  most  efficient ;  coun- 
ter irritants,  ergot  and  bromides  complete  the  list  of  thera- 
peutic agents. 

The  tonic  and  ergot  should  be  given  through  the  day, 
and  the  bromide  at  night  to  secure  rest  and  sleep. 

CliroEic  Ovaritis. — Pathology . — The  study  of  the  pathology 
of  ovaritis  derives  a  special  interest  from  the  fact  that  the 
ovary  differs  from  all  other  organs  of  the  body  in  that  its 
function  is  performed  at  the  expense  of  a  portion  of  its 
structure  which  is  never  restored  to  its  original  condition. 
The  rupture  of  each  Graafian  vesicle  in  ovulation  causes  the 
destruction  of  the  vesicle.  Rudimentary  vesicles  mature  and 
repeat  the  function  of  their  predecessors,  and  are  in  turn  de- 
stroyed. Finally,  the  supply  ceases,  and  the  ovary,  worn 
out  in  structure,  becomes  functionally  incompetent  long  be- 
fore the  general  organization  has  reached  the  end  of  its  life 
and  activity.  In  all  other  organs  of  the  body,  function  is 
effected  through  cellular  disintegration  and  restoration. 

This  peculiarity  in  the  natural  history  of  the  ovary  makes 
it  difficult  for  the  superficial  observer  to  distinguish  between 
the  normal  degeneration  and  the  structural  changes  which 
result  from  chronic  ovaritis.  Experts  also  find  it  no  easy 
matter  to   distinguish,    by  gross  appearances,   the  atrophy 


CHRONIC  INFLAMMATION  OF  THE   PELVIC  ORGANS.        225 

of  old  age  from  the  cirrhosis  and  contraction  of  inflam- 
mation. 

The  pathology  of  ovaritis  is  characterized  by  changes  of 
structure  brought  about  first  by  areolar  hyperplasia,  then  by 
atrophy  of  the  normal  tissues,  and  finally  ends  in  a  condition 
of  cirrhosis.  In  this  respect  the  morbid  process  and  its 
products  resemble  degeneration  more  than  inflammation, 
as  observed  in  other  organs.  In  the  natural  history  of  its 
pathology  chronic  ovaritis  is  more  like  certain  forms  of 
chronic  nephritis.  Owing  to  these  peculiar  and  distinguish- 
ing features,  the  affection  has  little  in  common  with  acute 
puerperal  or  specific  ovaritis,  or  with  secondary  acute 
ovaritis  due  to  peritonitis,  and  therefore  all  such  conditions 
will  be  carefully  excluded  from  the  discussion  of  the  subject 
in  hand. 

The  first  deviation  from  the  normal  toward  the  pathological 
is  deranged  innervation,  the  ovary,  owing  to  its  important 
office  and  intimate  relations  to  the  other  organs,  being  pecul- 
iarly prone  to  reflex  disturbances.  These,  though  temporary 
as  a  rule,  when  oft  repeated  and  prolonged  in  duration,  induce 
changes  in  the  circulation  which  impair  nutrition  and  finally 
produce  changes  of  structure.  This  ovarian  hypersemia,  the 
first  step  in  the  process,  may  subside,  and  complete  recovery 
follow.  Reliable  evidence  of  this  has  been  obtained,  first,  by 
clinical  observation  of  cases  which  have  given  all  the  signs 
and  symptoms  of  ovarian  congestion,  and  which,  under  care- 
ful management,  have  completely  recovered. 

Secondly,  I  have  not  infrequently  found,  by  inspection 
after  laparotomy,  a  prolapsed,  tender,  markedly  hypersemic, 
and  painful  ovary,  but  presenting  no  apparent  change  of 
structure  except  oedema,  that,  after  being  fixed  in  place  by 
stitching  the  utero-ovarian  ligament  to  the  upper  border  of 
the  broad  ligament,  was  completely  relieved.  The  continu- 
ation of  the  hypersemia  slowly  produces  those  structural 
changes  which  invariably  arise  from  prolonged  malnutrition. 
The  first  noticeable  changes  take  place  in  the  blood-vessels 
themselves.     They  become  dilated,  and  a  peculiar  degenera- 


226  MEDICAL   GYNECOLOGY. 

tion  of  their  walls  occurs.  These  changes  have  been  elabo- 
rately studied  by  Dr.  E.  Noeggerath,  who  advanced  the  idea 
that  these  vascular  changes  were  closely  related  to  the  gene- 
sis of  ovarian  cystomata.  This  may  be  true  in  certain  cases, 
but  it  more  frequently  ends  in  areolar  hyperplasia  of  the 
stroma,  which  gradually  goes  on,  and  in  time  crowds  out 
all  the  normal  structural  elements  of  the  ovary.  Finally 
a  true  cirrhosis  is  produced.  With  these  changes  in  the 
blood-vessels  the  circulation  is  interrupted  to  a  degree  that 
causes  oedema,  which  increases  the  size  of  the  ovary  and 
renders  it  softer.  Apoplexies  sometimes  occur,  and  occa- 
sionally one  or  more  of  the  blood-clots  may  be  seen  near 
the  surface.  These  conditions  can  be  distinguished  from  a 
diseased  Graafian  vesicle  by  the  staining  of  the  tissues  around 
the  clot.  Apoplexies  occur  in  the  early  stage  of  the  ova- 
ritis, and  gradually  disappear  as  the  process  of  hyper- 
plasia proceeds  to  a  complete  cirrhosis.  These  changes  ex- 
plain some  of  the  important  facts  in  the  clinical  history. 
The  ovary,  which  is  found  enlarged,  softened,  and  tender 
to  the  touch,  will,  in  months  afterward,  appear  subnormal 
in  size.  Likewise  the  same  lesions  may  be  recognized  upon 
inspection  after  laparotomy,  if  one  has  become  familiar  with 
them  by  previous  study. 

While  hyperplasia  of  the  stroma  is  going  on,  the  follicular 
elements  undergo  certain  changes.  The  contents  of  the  folli- 
cles become  cloudy  from  degeneration  of  the  epithelial  ele- 
ments. The  gross  appearance  of  the  ovary  at  this  time 
would  lead  one  to  suppose  that  there  were  a  number  of  vesi- 
cles approaching  maturity,  but  the  uncommon  number  of 
these  is  evidence  that  they  are  abnormal. 

Symptomatology. — The  history  of  chronic  ovaritis  in- 
cludes both  local  and  constitutional  symptoms.  The  consti- 
tutional derangements  are  not  acute,  but  are  nsually  marked 
by  depression  of  the  nutritive  and  nervous  systems.  The 
reflex  derangement  of  the  digestive  organs  is  manifested  by 
capricious  appetite,  nausea,  and  sometimes  gastralgia.  The 
bowels  are  usually  constipated  and  tympanitic.    There  is  often 


V 


CHRONIC  INFLAMMATION  OP   THE   PELVIC   ORGANS.        227 

nervous  debility  attended  with  great  emotional  disturbance. 
I  believe  that  I  have  seen  more  marked  derangement  of  the 
brain  and  nervous  system  caused  by  chronic  ovaritis  than  by 
the  reflex  influence  of  any  other  chronic  affection  of  the 
sexual  organs.  These  constitutional  symptoms  are  progres- 
sive, the  patient's  general  health  becoming  more  impaired 
month  after  month  as  the  disease  advances.  The  local  mani- 
festations are  pain  and  derangement  of  menstruation.  There 
is  often  menorrhagia  ;  in  fact,  that  is  the  rule,  but  in  cases  of 
long  standing  I  have  seen  amenorrhoea.  The  ovarian  pain — 
painful  ovulation — is  usually  increased  for  several  days  before 
menstruation,  and  is  relieved  to  some  extent  when  the  flow 
has  lasted  a  day  or  two.  The  menstrual  pain  is  much  more 
severe  and  persistent  if  there  be  a  uterine  disease  accompany- 
ing that  of  the  ovaries.  The  ovarian  pain  varies  according  to 
the  tissue  affected.  When  the  stroma  alone  is  the  site  of  the 
disease  the  pain  is  less  severe.  Much  more  suffering  is  ex- 
perienced when  there  is  circumscribed  peritonitis  or  sal- 
pingitis. Hysterical  women  sometimes  have  ovario-epilepsy 
when  suffering  from  this  affection. 

All  these  symptoms  are  aggravated  by  standing,  walking, 
riding,  or  sitting  in  a  stoo^oing  position  for  any  great  length  of 
time.  Most  comfort  is  obtained  by  the  recumbent  position. 
Sexual  excitation  and  coitus  cause  so  much  suffering  that  the 
patient  shrinks  from  both.  There  are  exceptions  to  this  rule, 
but  not  many. 

Physical  Signs. — The  ovaries  are  tender  to  the  touch,  and 
the  pain  excited  by  pressure  lasts  for  a  long  time  as  a  rule. 
The  character  of  the  pain  excited  by  the  touch  is  described 
as  ovarian.  When  the  ovary  is  enlarged  or  changed  in  form 
it  can  sometimes  be  made  out  by  the  bimanual  touch.  The 
ovary  is  usually  movable,  and  its  separation  from  the  uterus 
can  be  distinguished.  It  will  be  observed  that  the  symp- 
toms and  physical  signs  of  chronic  ovaritis  closely  resemble 
those  mentioned  as  occurring  in  ovarian  hypersemia.  The 
fact  is  that  the  two  affections  have  many  features  in  common ; 
hyperjemia  being  a  part  or  the  initial  stage  of  inflammation, 


228  MEDICAL  GYNECOLOGY. 

the  manifestations  of  the  two  affections  are  similar.  There  is 
a  close  resemblance  between  ovaritis  and  ovarian  neuralgia, 
but  the  differences  are  also  equally  marked.  In  neuralgia 
there  is  no  evidence  of  inflammation,  it  is  not  continuous, 
and  very  often  the  ovary  is  not  tender.  In  making  a  diag- 
nosis due  attention  should  be  given  to  all  the  facts  relative 
to  cause,  duration,  symptoms,  and  signs. 

Frognosis. — If  placed  under  treatment  early  the  chances 
of  recovery  are  favorable.  This  is  still  more  certain  if  only 
one  ovary  is  affected.  The  disease  may  go  on  in  one  ovary  to 
complete  destruction  of  the  organ,  and  after  this  premature 
atrophy  all  suffering  may  subside  except  occasional  neural- 
gic pain ;  and  the  other  ovary  may  perform  the  ovarian 
function.  In  case  the  disease  is  complicated  with  inflamma- 
tion of  the  neighboring  peritonaeum,  and  there  is  marked 
destruction  of  tissue  from  the  inflammation,  it  may  be  neces- 
sary to  remove  the  ovaries.  There  is  not  a  great  mortality 
from  this  affection.  I  have  never  seen  a  fatal  case,  but  I 
have  seen  several  in  which  life  was  not  worth  living. 

Causation. — A  poor  quality  of  ovaries,  due  to  imperfect  de- 
velopment and  growth,  predisposes  to  the  disease,  I  presume, 
because  that  rule  applies  to  all  organs  of  the  body.  Accord- 
ing to  my  observations,  the  cause  which  most  frequently  ob- 
tains is  imperfect  menstruation.  When  the  uterus  is  under- 
sized or  flexed  forward  or  backward,  and  the  menstrual  flow 
is  scanty  and  attended  with  pain,  the  ovaries  are  liable 
to  take  on  chronic  inflammation.  The  eruptive  fevers  are 
said  to  affect  the  ovaries,  but  I  believe  that  acute  ovaritis  is 
more  liable  to  occur  under  these  circumstances.  It  is  prob- 
ably true,  also,  that  gonorrhoea  causes  acute  rather  than 
chronic  ovaritis. 

The  strumous  diathesis  (which  I  understand  to  be  that 
condition  of  organization  which  invites  glandular  tubercu- 
losis) predisposes  to  chronic  ovaritis,  and  inherited  or  ac- 
quired syphilis  does  likewise. 

Much  has  been  written  about  endometritis  as  a  cause  of 
ovaritis,  upon  the  theory  that  the  structure  of  the  endome- 


CHRONIC   INFLAMMATION  OF   THE   PELVIC   ORGANS.        229 

trium  and  that  of  the  ovaries  have  a  common  embryonic 
genesis,  and  the  fact  that  the  two  diseases  are  often  found 
together,  but  this  is  still  an  open  question. 

General  Treatment. — The  indications  for  general  treat- 
ment are  to  lessen  the  blood  supply  and  relieve  pain  by  cor- 
recting the  deranged  innervation.  This  demands  rest  in  the 
recumbent  position  in  the  early  stages.  At  the  same  time 
general  exercise  should  be  enjoined,  either  by  massage  or 
gymnastic^exercise  in  the  reclining  position.  I  specially  de- 
sire to  commend  systematic  calisthenics,  in  the  recumbent 
position,  as  a  most  valuable  aid  in  improving  or  maintaining 
the  general  health  in  many  diseases  of  the  'pelvic  organs 
which  require  postural  treatment.  The  condition  of  the 
digestive  organs  should  be  carefully  watched.  The  poor 
appetite,  coated  tongue,  and  constipation,  or  the  capricious 
appetite,  flatulence,  and  occasional  diarrhoea,  can  be  relieved 
by  a  number  of  small  doses  of  mercury  and  a  laxative.  The 
saline  laxatives  are  the  best  when  they  act  without  causing 
flatulence.  The  use  of  Saratoga  waters  often  gives  good  re- 
sults by  improving  digestion  and  keeping  the  portal  circula- 
tion active.  By  keeping  up  a  free  elimination  by  the  bowels 
and  kidneys  much  benefit  is  obtained.  This  applies  in  cases 
that  are  apparently  debilitated,  but  are  really  suffering  from 
oppression.  Many  times  I  have  stopped  the  use  of  tonics, 
stimulants,  and  forced  feeding,  and  given  saline  laxatives, 
with  the  effect  of  increasing  the  patients'  strength.  To  re- 
lieve the  pain  and  lessen  the  hypersemia,  the  bromide  of  so- 
dium and  fluid  extract  of  hydrastis  canadensis  are  by  far 
the  most  potential  agents  that  I  have  found  ;  they  are  given 
in  combination,  and  in  doses  sufficient  to  produce  the  desired 
effect — twenty  to  thirty  grains  of  the  bromide  and  ten  to 
twenty  minims  of  the  hydrastis,  three  times  a  day,  until  the 
physiological  effects  of  the  bromide  are  noticed  in  a  mild  de- 
gree. If  the  hydrastis  is  given  alone  in  such  doses  it  some- 
times causes  pelvic  pain  of  a  dull  character,  but  when  com- 
bined with  the  bromide  it  has  no  such  effect.  These  agents 
are  most  efficacious  in  the  beginning  of  the  attack,  and  hence 


230  MEDICAL  aYNECOLOGY. 

they  should  be  discontinued  as  soon  as  the  pain  is  relieved 
in  a  marked  degree.  Should  the  pain  and  tenderness  return 
at  the  succeeding  menstrual  periods,  the  bromide  and  hy- 
drastis  should  be  resumed.  In  some  cases  much  larger  doses 
of  bromide  are  required,  and  in  others  it  fails  altogether  to 
relieve  pain.  Then  it  is  necessary  to  employ  other  agents, 
especially  during  menstruation.  Ten-grain  doses  of  salicyl- 
ate of  soda  and  five  of  antipyrine,  given  between  meals  and 
in  the  night,  when  the  stomach  is  empty,  answer  for  some  ; 
others,  more  especially  those  markedly  debilitated,  do  better 
on  full  doses  of  aromatic  spirits  of  ammonia,  camphor,  and 
chloric  ether,'  with  small  doses  of  cannabis  Indica.  This 
combination  is  best  suited  to  those  who  get  relief  from  gin 
or  whisky,  but  it  is  to  be  preferred,  as  alcoholic  stimulants 
ultimately  do  harm,  though  they  may  give  temporary  relief. 
Direct  or  local  treatment  should  be  adapted  to  the  social 
state  of  the  patient,  and  the  presence  or  absence  of  compli- 
cations, such  as  endometritis.  In  the  unmarried,  local  treat- 
ment is  often  injurious.  In  fact,  in  such  cases  it  is  better  to 
avoid  any  examination  of  the  pelvic  organs,  if  the  history  is 
sufficiently  clear  to  enable  one  to  make  a  diagnosis  with 
reasonable  certainty.  Hot  sitz  baths,  counter  irritation,  and 
hot  vaginal  douches,  the  latter  to  be  employed  by  a  com- 
petent nurse,  comprise  about  all  that  I  employ  in  the  way  of 
direct  treatment.  The  vaginal  douche  should  not  be  con- 
tinued unless  it  is  decidedly  sedative  in  its  effects.  Baths 
used  according  to  the  rules  of  modem  hydrotherapy  are  of 
great  service. 

In  weak,  nervous  patients  I  begin  with  the  wet-pack, 
used  for  half  an  hour  at  a  time.  Those  who  require  a  seda- 
tive are  put  into  water  at  a  temperature  of  95°  F.  for  ten  or 
twenty  minutes  and  then  dried  by  brisk  rubbing.  When 
the  sedative  effects  of  the  bath  are  no  longer  needed,  the 
tonic  bath  should  be  used. 

The  general  treatment  thus  briefly  outlined  gives  relief 
from  the  more  pronounced  symptoms.  The  pain  becomes 
less,  and  the  tenderness  also.     The  general  health  improves, 


CHROKIC  INFLAMMATION  01"^  THE  PELVIC   ORGANS.        231 

and  the  pelvic  congestion  subsides.  This  is  apparent  in  the 
color  of  the  mucous  membrane,  and  the  improvement  of  the 
menstrual  functions.  The  treatment  should  now  be  modified. 
Tonics  and  laxatives  may  still  be  required,  but  alteratives 
are  also  indicated.  Iodine  and  mercury  are  the  chief  agents. 
They  act  upon  the  ovaries,  as  they  do  upon  all  glandular 
organs,  and  modify  or  arrest  the  morbid  histological  changes 
v^hich  take  place  slowly — small  doses  of  bichloride  of  mer- 
cury, with»  chloride  of  iron,  when  iron  is  indicated,  followed 
by  sirup  of  the  iodide  of  iron,  in  doses  as  large  as  can  be 
borne.  These  can  only  be  used  when  the  bromides  are  re- 
linquished. When  giving  these  alteratives  the  patient  often 
misses  the  bromides  used  to  produce  sleep.  Sulphonal  at 
such  times  is  of  great  value.  In  fact,  it  is  the  most  potent 
sedative  that  is  at  the  same  time  free  from  ultimate  or  after- 
effects that  are  unfavorable  that  we  have  in  gynecological 
practice.  When  a  sedative  is  required  while  iodine  or  mer- 
cury is  being  used,  I  find  that  ten  grains  of  salicylate  of 
sodium  and  five  grains  of  antipyrine,  three  times  a  day  an 
hour  before  meals,  give  much  relief,  especially  in  those  who 
suffer  from  nervous  dyspepsia  and  flatulence. 

Important  elements  in  the  treatment  are  patience  and 
careful  watching.  Improvement  comes,  the  patient  or  the 
physician  gives  up  treatment,  and  there  is  danger  of 
relapse.  The  poor  in  hospitals  often  suffer  for  want  of 
time  for  prolonged  treatment,  and  this  frequently  tempts 
the  surgeon  to  seek  more  prompt  relief  by  removal  of  the 
ovaries.  This  does  not  apply  to  those  who  have  time  and 
means  to  secure  the  needed  care.  Chronic  ovaritis  is  fre- 
quently complicated  with  prolapsus  of  the  ovaries.  This 
generally  requires  surgical  treatment,  and  therefore  is  not  to 
be  considered  here. 

Chronic  Salpingitis.— Very  little  was  known  on  this  subject 
until  of  late  years,  when  surgeons  revealed  the  fact  that 
salpingitis  often  terminated  in  pyosalpinx,  which  required 
extirpation  of  the  tubes.  Opportunity  was  thus  afforded  for 
the  study  of  the  pathology  of  this  affection  upon  the  living 


232  MEDICAL  GYNECOLOGY. 

subject.  I  was  also  assured  that  the  milder  forms  of  salpin- 
gitis ended  in  recovery  ;  at  least  the  process  subsided  before 
advancing  to  the  suppurative  stage.  This  is  of  interest, 
as  it  shows  that  medical  care  alone  is  sufficient  in  this  form 
of  the  disease  ;  therefore  the  physician  should  be  prepared 
for  the  management  of  such  cases.  He  should  consider  the 
subject  well,  for  the  further  reason  that  he  may  know  the 
limits  of  his  ability  to  manage  such  cases,  and  at  the  same 
time  be  able  to  tell  when  they  should  be  transferred  to  the 
surgeon. 

PatJiology. — There  is  general  congestion  of  all  the  struc- 
tures of  the  tube.  The  mucosa  is  thickened  at  first,  and 
secretes  a  fluid  which  is  thin  and  watery,  or  like  milk  and 
water,  but  does  not  contain  pus.  In  the  severer  forms  which 
border  upon  the  acute  there  is  slight  perisalpingitis — that  is, 
inflammation  of  the  peritonaeum  covering  the  tube.  The  prod- 
ucts of  such  bygone  inflammation  were  found  in  connection 
with  structural  changes  in  the  tube  indicative  of  chronic 
salpingitis.  These  observations  were  often  made  in  years 
gone  by,  and  they  have  all  been  verified  during  the  practice 
of  abdominal  surgery.  As  a  rule,  both  ends  of  the  tube  are 
closed  by  inflammatory  adhesions.  This  is  a  peculiar  effect 
of  inflammation  of  the  mucous  membrane,  and  is  exceptional. 
Sometimes  the  inflammation  subsides,  leaving  no  trace  of  the 
disease,  excepting  closure  of  the  canal  of  the  tube. 

Occasionally  the  serous  fluid  accumulates  in  the  tube,  and 
distending  it,  forms  a  small  cystic  tumor,  or  there  may  be 
several  cysts  without  intercommunication.  In  this  condition 
the  walls  of  the  tube  usually  become  extremely  thin.  This  is 
known  as  tubal  dropsy  or  hydrosalpinx.  The  uterine  end  of 
the  tube  that  was  closed  at  the  beginning  of  the  inflammation 
gives  way  and  the  fluid  is  discharged  into  the  uterus.  This 
may  end  the  whole  trouble,  or  the  tube  become  refilled 
and  again  emptied,  a  process  which  may  occur  several  times, 
and  finally  recovery  may  come  after  a  long  time. 

Symptoms. — This  affection  so  often  follows  chronic  endo- 
metritis that  the  symptoms  of  salpingitis  are  often  merged 


CHEONIC  INFLAMMATION   OP  THE  PELVIC  ORGANS.        233 

with  those  of  the  primary  disease,  or  are  marked  by  it 
until  slight  pelvic  peritonitis  occurs.  Usually  there  is  pain 
in  the  affected  tube,  which  comes  and  goes,  and  is  more  de- 
cided at  the  menstrual  period.  Standing  or  walking  common- 
ly increases  the  pain.  There  is  no  symptomatic  fever,  but  the 
nutritive  and  nervous  systems  are  disturbed  less  or  more.  In 
short,  the  symptoms  are  the  same  as  in  chronic  ovaritis,  but 
not  so  severe  or  well  defined,  unless  peritonitis  comes  in  as  a 
complication ;  then  there  may  be  slight  symptomatic  fever 
and  well-defined  pain. 

The  physical  signs  are  tenderness  on  pressure  in  the  iliac 
region,  and  by  the  bimanual  examination  the  tube  may  be 
felt  to  be  indurated,  or  if  dropsical  a  tumor  will  be  found. 
The  oblong  f6rm  of  the  tumor  or  a  series  of  tumors  is 
characteristic  of  the  disease. 

Causation. — Subacute  catarrhal  salpingitis  is  nearly  al- 
ways secondary,  and  therefore  caused  by  the  same  form  of 
corporeal  endometritis.  As  it  frequently  occurs  in  connec- 
tion with  chronic  ovaritis,  it  is  possible  that  the  same  cause 
obtains  in  both  affections.  The  causes  of  specific  and  septic 
forms  of  salpingitis  are  not  to  be  considered  in  this  con- 
nection. 

Treatment. — As  chronic  salpingitis  is  almost  always  sec- 
ondary to  chronic  corporeal  endometritis  or  ovaritis,  the  med- 
ical treatment  must  be  directed  to  the  primary  disease.  For 
further  details  the  reader  is  referred  to  the  subject  given 
under  the  treatment  of  chronic  metritis  and  ovaritis. 


CHAPTER  XX. 

DISPLACEME:^rTS    OF   THE   UTEEIJS. 

Dislocation^  of  the  uterus  belongs  mainly  to  surgery, 
Giving  to  tlie  fact  that  the  more  pronounced  cases  require 
surgical  treatment.  There  are,  however,  many  forms  which 
when  seen  early  can  be  arrested  by  such  general  and  postural 
treatment  as  comes  ^vithin  the  province  of  the  physician. 
Such  cases  are  met  among  young  women  who  prefer  to  be  re- 
lieved without  local  surgical  treatment,  and  there  are  others 
still  who  suffer  displacement  after  confinement,  that  come 
under  the  same  treatment.  The  physician  should  be  suffi- 
ciently familiar  with  the  clinical  history  of  uterine  displace- 
ments to  make  a  presumptive  diagnosis,  and  decide  with  a 
degree  of  certainty  whether  a  given  case  can  be  managed  by 
him  or  should  be  at  once  sent  to  the  special  surgeon. 

More  than  that,  the  physician  when  familiar  with  this  sub- 
ject in  a  general  way  can  do  much  to  prevent  dislocations  of 
the  pelvic  organs  that  are  likely  to  be  produced  during  devel- 
opment, or  to  follow  parturition,  premature  or  at  term. 

He  is  also  prepared  to  institute  treatment  upon  the  first 
indications  of  trouble,  and  therefore  can  do  much  good  with 
the  treatment  to  be  described. 

The  position  of  the  uterus  in  the  pelvis  and  the  way  that 
it  is  held  in  its  place  must  be  briefly  studied  in  order  that  the 
nature  and  causes  of  disjolacements  and  their  treatment  may 
be  more  easily  understood. 

In  the  first  place,  it  may  be  said  that  the  uterus  is  wholly 
within  the  ttue  pelvis. 

The  line  on  the  diagram  running  between  the  symphysis 

234 


DISPLACEMENTS  OF  THE  UTERUS. 


235 


Fig.  13. — Section  of  pelvis,  showing  its 
inclination  and  the  axis  of  the  inlet. 


pubis  and  the  promontory  of  the  sacrum  divides  the  true  pel- 
vis from  the  abdomen,  and  all  the  pelvic  organs,  the  uterus 
included,  are  belovr  this  plane — the  superior  strait,  as  the  ob- 
stetricians call  it.  The  long  diameter  of  the  uterus  corre- 
sponds very  nearly  to  the  axis 
of'  this  plane,  as  represented 
by  the  line  (Fig.  13),  and  it  is 
equidistant  from  the  sides  of 
the  pelvis. 

The  position  of  the  uterus 
varies  according  to  circum- 
stances ;  but  in  all  its  changes 
it  returns  to  the  axis  of  the 
inlet  of  the  pelvis,  slightly  be- 
hind the  center  of  the  true 
conjugate.  This  is  sufficiently 
correct  to  form  a  basis  from 
which  clinical  studies  may  be 
conducted. 

Next  in  the  order  of  inquiry  are  the  anatomical  structures 
by  which  the  uterus  is  held  in  position.  This  requires  a  con- 
sideration of  the  structural  associations  of  the  uterus  and  all 
the  other  pelvic  organs  and  tissues.  The  position  of  the  sev- 
eral pelvic  organs  is  as  follows :  The  uteres  in  the  center, 
Fallopian  tubes  and  ovaries  on  either  side  the  bladder,  in 
front,  rectum  behind,  and  the  vagina  below.  Covering  all 
these,  except  the.  vagina,  is  the  peritonaeum,  out  of  which 
are  formed  the  ligaments  which  have  much  to  do  in  keeping 
the  uterus  in  place.  The  peritonaeum,  while  it  covers  the 
pelvic  organs,  is  attached  to  the  bony  walls  of  the  pelvis 
through  the  medium  of  the  periosteum  and  areolar  tissue,  so 
that  one  end  of  each  ligament  may  be  said  to  have  an  attach- 
ment to  the  inner  side  of  the  pelvic  bones.  The  round  liga- 
ments contain  muscular  tissue  in  considerable  quantity,  and 
are  really  outgrowths  from  the  uterus  in  the  form  of  round 
cords,  which  start  from  the  uterus  near  the  proximate  ends  of 
the  Fallopian  tubes,  and,  sweeping  round  the  outside  of  the 

16 


236  MEDICAL  GYNECOLOGY. 

pelvis,  pass  out  througli  the  inguinal  rings  into  the  labia 
majora. 

The  utero-vesical  ligaments,  in  addition  to  their  attach- 
ments to  the  uterus  and  bony  walls  of  the  pelvis,  are  also  con- 
nected indirectly  to  the  anterior  vaginal  wall  by  intervening 
areolar  tissue.  The  utero-sacral  are  connected  in  the  same  in- 
direct way  with  the  upper  portion  of  the  posterior  vaginal 
wall,  and  also  to  the  rectum,  on  the  left  side  at  least. 

At  the  junction  of  the  supra- vaginal  portion  of  the  cervix 
and  body  of  the  uterus  all  the  ligaments,  except  the  round 
ones,  are  attached.  Here  also  the  anterior  and  posterior 
vaginal  wall  and  a  portion  of  the  bladder  join  these  other 
structures. 

The  union  of  these  structures  at  this  point  is  not  direct, 
but  is  through  the  intervention  of  areolar  tissue  which  is 
found  in  considerable  quantity  in  this  region.  From  this  it 
will  be  seen  that  these  ligaments  are  continuous  from  side  to 
side,  and  also  from  before  backward. 

The  chief  function  of  these  ligaments,  aided  by  the  ante- 
rior vaginal  wall,  is  to  keep  the  uterus  and  bladder  in  posi- 
tion. This  is  evident  from  the  fact  that  the  uterus  remains 
in  place  for  a  considerable  time  when  all  other  means  of  sup- 
port are  removed. 

A  similar  function  may  be  claimed  for  the  round  liga- 
ments, at  least  so  far  as  their  effect  in  preventing  the  back- 
ward displacement  of  the  uterus. 

The  ligaments,  the  vagina,  and  the  other  pelvic  organs  all 
aid  in  keeping  the  uterus  in  position,  and  are  sufficient  to  do 
so  under  ordinary  circumstances.  Still,  when  extraordinary 
strain  is  brought  to  bear  upon  the  pelvic  organs,  the  ]3elvic 
floor  supplements  these  supporting  structures.  Moreover, 
the  relation  of  the  trunk  to  the  pelvis  has  much  to  do,  if  not 
in  keeping  the  pelvic  organs  in  place,  certainly  in  freeing 
them  from  pressure  from  above. 

The  pelvis  is  so  placed  that,  in  the  erect  posture,  its  cavity 
is  behind  rather  than  beneath  the  abdomen,  and  the  abdomi- 
nal muscles  partially  divide    the  greater  cavity  from   the 


DISPLACEMENTS  OF  THE  UTERUS. 


237 


lesser.  This  is  shown  in  the  accompanying  diagram,  where 
the  arrow  indicates  the  direction  of  the  force  transmitted  to 
the  pelvis  through  pressure  from  above  (Fig.  14). 

There  is  very  little  direct  abdominal  pressure  upon  the 
pelvic  organs  in  the  erect  posture.     The  axis  of  the  pelvis 
is  backward  and   downward, 
while   that    of    the    abdomen 
is  perpendicular,  so  that  the 
pressure  is  indirect  from  above. 

Some  claim  that  a  suction 
power  is  exerted  upon  the  pel- 
vic contents  by  the  diaphragm. 
It  is  said  to  act  like  a  piston 
in  the  cylinder  of  a  pump. 
There  is  reason  to  believe  there 
is  something  in  this,  from  the 
fact  that,  on  examination 
through  a  Sims  speculum,  the 
uterus  is  seen  to  rise  and  fall 
with  respiration.  This  motion 
is  to  a  large  extent  arrested 
when  the  patient  is  in  the  erect 
posture. 

If  it  is  a  fact,  as  it  appears 
to  be,  that  the  abdominal  organs  are  fixed  by  suspension  in 
their  normal  position,  and  that  in  their  descent  during  this 
limited  motion  the  pressure  upon  the  pelvic  organs  is  in- 
direct, then  this  relationship  contributes  to  maintain  the 
position  of  the  pelvic  organs  as  surely  as  if  there  were  some 
traction  or  suction  action  of  the  diaphragm  tending  to  draw 
these  organs  upward. 

In  regard  to  the  pelvic  floor  and  its  relations  to  the  dis- 
placements of  the  uterus,  it  is  only  necessary  to  say  that, 
while  the  pelvic  floor  does  not  directly  support  the  uterus,  it 
indirectly  aids  in  doing  so. 


Fig.  14. — The  normal  inclination  of  the 
pelvis  and  the  transmission  of  force 
from  above. 


238  MEDICAL  GYNECOLOGY. 

DISLOCATIONS   OF  THE  UTERUS. 

The  uterus  is  peculiarly  subject  to  physiological  changes 
of  position.  The  bladder  in  front  causes  the  uterus  to  move 
forward  and  backward  according  to  its  dilatations  and  con- 
tractions. In  a  similar  but  much  less  extensive  way,  disten- 
tion of  the  rectum  acts  to  push  the  uterus  forward.  The  ab- 
dominal pressure  from  above  is  constantly  changing,  and  is, 
therefore,  constantly  affecting  the  position  of  the  uterus  less 
or  more. 

These  changes  of  position,  when  limited  in  degree,  are 
physiological,  the  organ  promptly  returning  to  its  original 
position  as  soon  as  the  displacing  influence  is  removed.  It  is 
only  when  the  uterus  remains  displaced  permanently,  or  is 
carried  far  beyond  the  physiological  limits,  that  the  disloca- 
tion is  to  be  regarded  as  pathological.  When  this  occurs,  the 
malposition  gives  rise  to  suffering  from  deranged  menstrua- 
tion, circulation,  and  innervation,  and  in  some  cases  to  steril- 
ity. Usually  the  functions  of  the  bladder  and  rectum  are 
'disturbed  and  the  general  system  suffers  from  reflex  influ- 
ences. It  is  only  when  such  symptoms  as  these  are  present 
that  displacements  of  the  uterus  claim  the  attention  of  the 
gynecologist. 

There  are  a  great  many  forms  of  displacement  of  the 
uterus,  if  every  change  of  position  of  that  organ  be  taken  into 
account,  but  of  those  that  occur  as  primary  affections  there 
are  only  two  that  are  often  seen,  and  one  that  is  very  rare. 
These  are  downward,  backward,  and  forward — that  is,  pro- 
lapsus, retroversion,  and  anteversion. 

Prolapsus  and  retroversion  are  really  the  only  forms  of 
displacement  which  practically  claim  attention  in  this  con- 
nection. These  two  forms  of  displacement  are  the  only  con- 
ditions of  malposition  that  can  be  directly  treated  with  favor- 
able results. 


DISPLACEMENTS  OP  THE  UTERUS.  239 

PROLAPSUS  AND   RETROVERSION   OF  THE  UTERUS. 

The  downward  and  backward  displacements  of  tlio  uterus 
are  so  much  alike  in  clinical  history,  causation,  and  medical 
treatment,  that  I  shall  consider  the  two  together,  pointing  out 
any  marked  differences  that  the  physician  ought  to  know. 
The  pathology  in  every  detail  must  be  known  to  the  sur- 
geon who  undertakes  the  treatment  of  displacements  caused 
by  injuries  which  require  operations  or  pessaries  for  their 
relief ;  but  the  physician  who  deals  with  the  simpler  cases 
can  not  apply  such  knowledge  practically.  Great  refine- 
ments have  been  made  in  the  classification  of  uterine  dis- 
placements, but  for  practical  purposes  the  simplest  is  all- 
sufficient. 

Prolapsus  is  simply  a  descent  of  the  uterus.  All  the  de- 
grees of  prolapsus  in  which  the  uterus  still  remains  within 
the  vulva  are  termed  incomplete,  while  those  in  which  it  pro- 
trudes partially  or  completely  beyond  the  vulva  are  called 
complete.  Retroversion  is  displacement  backward.  Two  or 
more  degrees  are  usually  given.  In  the  first  the  fundus  re- 
mains Just  beneath  the  promontory  of  the  sacrum,  and  in  the 
other  the  uterus  is  at  right  angles  to  the  axis  of  the  pelvis. 
There  is  always  some  retroversion  connected  with  prolapsus, 
and  some  prolapsus  in  retroversion. 

This  latter  arrangement  of  the  subject  is  perhaps  as  easily 
comprehended  and  as  useful  in  practice  as  any  other. 

Pathology. — Displacements  of  the  uterus  take  place 
slowly,  as  a  rule.  In  the  few  cases  that  I  have  had  an  oppor- 
tunity of  M^atching  from  beginning  to  completion,  the  dis- 
placement has  been  gradual.  At  first  the  uterus  descended 
to  the  first  degree  of  prolapsus,  and  then  to  the  second,  and 
finally  to  the  third  or  complete  displacement.  The  time  oc- 
cupied in  completing  these  changes  of  position  varies  from 
months  to  years.  The  changes  which  take  place  in  the  sup- 
ports of  the  uterus  and  the  other  pelvic  organs  during  the 
progressive  development  of  the  malposition  are  usually  the 
same  in  all  cases  with  few  exceptions,  but  the  order  in  which 


240  MEDICAL  GYNECOLOGY. 

they  appear  differs  according  to  the  cause.  This  again  de- 
pends upon  the  point  in  the  structures  at  which  the  lesions 
begin  to  develop.  There  are  three  methods  of  development 
of  prolapsus  and  retroversion.  In  the  first,  the  uterus  leaves 
its  place  because  it  is  too  heavy  and  makes  too  great  de- 
mands upon  its  immediate  supports,  or  else  these  supports 
become  defective  from  pathological  changes.  The  second  in 
order  is  by  loss  of  the  pelvic  floor,  which  permits  the  vagina, 
bladder,  and  part  of  the  rectum  to  descend,  and  then  the 
uteras  follows.  The  third  in  order  is  made  up  of  the  two 
others,  the  first  and  the  second,  all  the  conditions  mentioned 
in  those  being  operative  at  the  same  time. 

The  changes  in  the  supports  are  elongation  from  imperfect 
involution  after  parturition,  or  stretching  produced  by  en- 
largement of  the  uterus,  or  pressure  on  it  from  above  by  long 
standing,  stooping,  or  lifting.  In  the  former  condition  the 
supports  are  too  long ;  in  the  latter  they  are  attenuated  as 
well  as  elongated.  There  is  also,  in  some  cases,  loss  of  the 
areolar  and  adij)ose  tissue,  and  the  pelvic  fascia  has  lost  its 
strength  of  fiber.  This  traction  upon  the  blood-vessels  is  pre- 
sumed to  interrupt  the  return  circulation.  Whether  that  is  a 
fact  or  not,  there  is  usually  a  passive  hypersemia  of  the  parts 
in  these  displacements.  These  changes  of  the  position  and 
relations  of  these  parts  are  gradually  developed. 

The  second  order  of  the  development  of  prolapsus — that 
is,  where  the  loss  of  the  pelvic  floor  is  the  starting  point  of 
the  malposition — belongs  to  surgery  and  need  not  be  dis- 
cussed here. 

Prolapsus  of  long  standing  changes  the  structure  of  all  the 
tissues.  Atrophy  of  the  muscular  tissue  of  the  vagina  and 
pelvic  floor  occurs,  and  the  ligaments  of  the  uterus  lose  their 
characteristics  so  that  they  can  not  be  restored  to  their  origi- 
nal state  by  any  means. 

There  is  a  prolapsus  which  occurs  as  the  result  of  degener- 
ation of  the  supports  of  the  uterus.  It  occurs  in  feeble  old 
women,  and  is  taken  up  in  the  diseases  of  old  age. 

Symptomatology.  —The  natural  history  of  prolapsus  uteri, 


DISPLACEMENTS  OP  THE  UTERUS.  241 

as  manifested  by  symptoms,  differs  to  some  extent  in  differ- 
ent cases,  though  the  pathological  conditions  appear  to  be  the 
same  in  all.  The  suffering  caused  varies  according  to  the 
general  health  and  nervous  sensitiveness  of  the  subjects  af- 
fected. 

The  symptoms  indicative  of  these  displacements  may  be 
classed  under  two  heads  :  First,  the  derangement  of  the  func- 
tions of  the  other  pelvic  organs,  and,  second,  the  disordered 
nutrition  ^f  the  tissues  of  the  pelvic  viscera  generally.  The 
dragging  of  the  uterus  upon  the  bladder  and  rectum  and  the 
abnormal  pressure  cause  irritation,  which  gives  rise  to  rectal 
and  vesical  tenesmus.  The  constant  desire  to  evacuate  the 
rectum  and  bladder  is  often  very  distressing.  These  symp- 
toms are  greatly  aggravated  by  walking,  lifting,  coughing, 
and  especially  by  standing,  and  they  are  all  relieved  in  a  very 
marked  degree,  often  completely  so,  by  lying  down.  This 
difference  in  the  feelings  of  the  patient,  when  in  the  erect  or 
recumbent  position,  is  a  diagnostic  point  of  very  great  value. 
The  recumbent  position  generally  gives  relief  in  the  majority 
of  the  diseases  of  the  pelvic  organs,  but  not  so  markedly  as 
in  displacements  of  the  uterus. 

The  malnutrition  produced  by  irritation  and  deranged  cir- 
culation leads  in  time  to  inflammatory  affections  of  the  uterus 
and  other  pelvic  organs,  not  an  acute  inflammation  which  can 
be  seen,  but  a  hypersemia  accompanied  by  tissue  changes 
such  as  areolar  hyperplasia  and  catarrhal  states  of  the  mucous 
membrane.  It  is  probable  that  the  endometritis  so  common 
in  displacements  may  in  many  cases  precede  the  displace- 
ment, but  the  displacement  certainly  tends  to  keep  it  up. 
Menstruation  is  often  deranged,  menorrhagia  is  common,  and 
in  retroversion  the  flow  is  offensive  in  odor. 

The  symptoms  manifested  by  the  general  system  in  this 
affection  are  not  marked  or  special.  Beyond  the  backache 
and  deranged  digestion,  and  the  depression  which  comes  from 
a  consciousness  of  having  some  chronic  ailment  which  im- 
pairs locomotion  and  general  usefulness,  there  is  not  much 
that  need  be  mentioned. 


242 


MEDICAL  GYNECOLOGY. 


Causation. — The  fine  adjustment  of  the  uterus  and  the 
means  which  keep  that  organ  in  its  place,  and  yet  permit 
considerable  motion,  are  such  that  any  increase  of  weight  of 
the  one  or  loss  of  strength  of  the  other  will  cause  displace- 
ment. The  formation  of  the  pelvis,  and  its  position  in  re- 
lation to  the  vertebral  column  ;  the  character  of  the  fiber  of 
the  uterine  supports,  the  quantity  and  consistence  of  the 
areolar  and  adipose  tissue  ;  one's  habits  in  regard  to  clothing, 
position  in  standing  and  sitting,  if  maintained  unduly  long, 

character  of  occupation,  strength 
or  weakness  of  general  organi- 
zation ;  and  the  accidents  and 
injuries  incident  to  child-bear- 
ing— all  have  certain  influences 
in  causing  dislocations  of  the 
uterus, 

A  shallow  and  wide  pelvis 
which  is  more  than  sufiicient  for 
the  accommodation  of  its  con- 
tents, while  it  is  favorable  to 
easy  parturitions,  predisposes  to 
descent  of  the  uterus.  Again, 
if  the  pelvis  is  tilted  forward, 
so  that  it  is  brought  more  imme- 
diately under  the  axis  of  the  ab- 


FiG.  15. — Increased  inclination  of  in 
let.    Pelvic  organs  escape  pressure. 


domen,  the  pelvic  organs  are 
constantly  under  greater  press- 
ure than  norma],  and  prolapsus  and  retroversion  are  likely  to 
occur.  These  facts  regarding  the  form  and  position  of  the 
pelvis  are  factors  of  great  importance  in  the  problem  of  uter- 
ine displacement,  and  deserve  more  attention  than  has  been 
given  to  them. 

The  habit  of  walking  erect  has  the  effect  of  maintaining 
this  favorable  relation  of  the  abdomen  and  pelvis,  while 
stooping  disturbs  this  harmony  of  relative  positions.  In 
this,  both  in  regard  to  formation  and  habit  of  standing  and 
walking,  there  is  the  greatest  diversity  among  women.     The 


DISPLACEMENTS  OF   THE  UTERUS.  243 

tissues  of  the  uterine  supports,  when  defective  in  quantity  or 
quality,  are  incapable  of  performing  their  functions.  These 
effects  may  be  the  result  of  imperfect  development  such  as 
occurs  in  those  of  sedentary  habits  in  youth,  or  they  may 
come  from  debilitating  diseases.  In  the  one  case  they  have 
never  been  w^ell  developed,  and  in  the  other  they  have  be- 
come atrophied.  Standing  and  w^alking  to  an  extent  that  is 
fatiguing  bring  undue  strain  upon  the  pelvic  organs,  and,  if 
persisted  in,  will  in  time  produce  prolapsus.  Active  exercise, 
with  liberal  periods  of  rest,  will  tend  to  strengthen  the 
uterine  supports,  but  fatigue  will  overcome  their  power  of 
resistance.  Stooping  forward  while  in  the  sitting  position 
has  a  twofold  injurious  influence — it  interrupts  the  return 
circulation  in  the  pelvis  and  impairs  the  nutrition  of  the 
organs,  and  brings  increased  downward  pressure  to  bear  on 
them.  The  position  of  the  girl  at  the  sewing  machine  or 
typewriter,  and  that  of  the  lady  of  leisure,  bent  over  in  her 
easy-chair  while  reading  a  novel,  are  alike  hurtful ;  but  worst 
of  all,  the  schoolgirl,  bending  over  her  desk  all  day,  while 
her  body  is  or  should  be  developing,  suffers  the  most  injury. 
Among  the  errors  in  the  use  of  clothing  the  abuse  of  corsets 
is  a  subject  already  discussed. 

Heavy  lifting,  if  persisted  in,  is  a  cause  of  displacement. 
This  is  noticed  among  the  poor  who  do  heavy  work.  The 
women  of  India,  who  were  at  one  time  supposed  to  bear 
children  with  ease  and  impunity,  and  to  suffer  less  from 
uterine  affections  than  our  American  women,  are  very  sub- 
ject to  complete  prolapsus  uteri,  caused,  no  doubt,  from  their 
want  of  care  after  confinement  and  in  carrying  heavy  bur- 
dens. General  weakness,  induced  by  exhausting  diseases 
and  extreme  old  age,  affects  the  pelvic  organs'  very  decided- 
ly. This,  no  doubt,  is  the  cause  of  prolapsus  uteri  in  women 
with  consumption  and  in  the  very  aged. 

The  most  important,  certainly  the  most  frequent,  causes 
of  uterine  displacement  are  the  injuries  and  improper  man- 
agement incident  to  child-bearing.  The  condition  of  the 
uterine  supports  after  parturition  is  that  they  are  all  greatly 


2M  MEDICAL  GYNECOLOGY. 

enlarged  througli  the  growth  of  gestation,  and,  while  they 
are  competent  to  maintain  the  large  uterus  which  rests  in  the 
abdominal  cavity,  they  must  undergo  involution  in  conjunc- 
tion with  the  diminution  of  the  uterus.  If  this  involution 
fails  in  the  uterine  ligaments  and  vagina  while  it  goes  on  in 
the  uterus  the  supports  fail,  because  they  are  too  long  and 
relaxed.  Imperfect  involution,  not  only  of  the  uterus  but 
of  all  the  other  tissues  and  organs  of  the  pelvis,  is  seen  to 
give  rise  to  displacement.  This  imperfect  involution  may 
be  due  to  post-partum  inflammation,  or  to  the  patient  re- 
suming the  active  duties  of  life  before  involution  is  com- 
pleted. 

Finally,  enlargement  of  the  uterus,  whether  from  imper- 
fect involution,  inflammation,  or  the  presence  of  neoplasms, 
will  cause  prolapsus.  This  will  occur  although  all  the  sup- 
ports may  be  normal ;  the  balance  between  the  supports  and 
the  organs  to  be  supported  being  disturbed  by  the  increased 
weight  of  the  uterus,  descent  will  occur. 

Treatment. — The  medical  treatment  of  displacements  of 
the  uterus  is  limited  to  recent  cases  that  are  caused  by  tem- 
porary enlargement  of  the  uterus  and  defects  of  the  uterine 
ligaments,  and  cases  in  which  the  uterus  can  be  readily  made 
to  resume  its  normal  position.  This  treatment  is  sufficient 
in  itself  and  wholly  within  the  province  of  the  physician. 
The  surgeon  also  finds  it  applicable  and  valuable  in  conjunc- 
tion with  surgical  treatment. 

The  indications  are,  first,  to  correct  any  defects  in  cloth- 
ing and  habits  of  life  that  may  cause  or  keep  up  the  dis- 
placement. Loose,  light  clothes  should  be  worn,  and  sitting, 
standing,  walking,  or  lifting  heavy  weights  should  be  avoided. 
The  next  thing  in  order  is  to  restore  the  uterus  to  its  position 
by  the  knee-chest  position.  This  I  have  employed  in  an  ex- 
aggerated form  by  placing  the  patient  upon  a  movable  lounge 
which  can  be  tilted.     (See  Fig.  16.) 

This  position  should  be  taken  two  or  three  times  a  day, 
and  maintained  for  five  or  ten  minutes.  Then  the  patient 
should  rest  upon  the  back  or  side,  on  the  table  or  lounge 


DISPLACEMENTS  OF  THE   UTERUS. 


245 


tilted  toward  the  head.  When  such  a  lounge  is  not  avail- 
able, an  ordinary  sofa  can  be  raised  at  one  end  and  made  to 
answer  the  purpose.  By  this  postural  treatment  the  uterus 
can  be  gradually  made  to  assume  its  normal  position.  I  am 
aware  that  some  of  my  readers  will  feel  that  this  is  a  slow 
and  uncertain  way  of  treating  displacements  ;  but  I  must  say 


Fig.  16. 


that  in  the  class  of  cases  which  I  have  described  and  to 
which  this  method  is  adapted,  it  will  be  found  satisfactory 
to  the  general  practitioner,  and  when  successful,  as  it  often  is, 
gives  a  far  more  permanent  cure  than  is  usually  obtained  by 
the  use  of  pessaries. 

In  connection  with  the  postural  treatment  proper  external 
support  should  be  employed. 

A  careful  and  exact  investigation  concerning  the  center  of 
gravity  and  lines  of  support  has  been  made  by  Dr.  Bewees, 
of  Salina,  Kansas,  whose  conclusions  may  be  summed  up 
briefly  as  follows  :  The  erect  posture  consists  principally  in  a 
transverse  and  antero- posterior  balance  of  the  body  (upper 
half)  upon  the  center  of  gravity,  which  point  is  in  the  lumbar- 
spinal  curve  (see  Fig.  17). 

We  notice  that  the  lumbar  spinal  curve  lies  on  a  line  per- 
pendicular to  the  plane  of  the  ankle,  and  can  thus  preserve 


246 


MEDICAL  GYNECOLOGY. 


spinal  symmetry  and  pelvic  obliquity.  Hence  it  is  impos- 
sible for  the  upper  part  of  the  body  to  make  any  decided 
movement  without  the  lumbar  spine  first  shifting  its  posi- 
tion :  in  stooj)ing,  it  retreats  backvrard  ;  in  bending  back,  the 
center  advances. 

When  this  lumbar  spine  is  misplaced,  as  in  deformities,  it 


Fig.  17. 


Fig.  18. 


must  be  so  acted  on  that  the  gravity  of  the  body  brings  it 
back  to  the  true  axis. 

A  normal  body  in  the  erect  position,  showing  the  proper 
relationship  of  the  viscera,  is  seen  in  Fig.  18. 

It  seems  that  the  pelvic  organs  are  normally  supported 
and  kept  in  place  by  the  obliquity  of  the  pelvis  and  the  elas- 
ticity of  the  abdominal  and  spinal  muscles,  both   of  which 


DISPLACEMENTS  OP  THE    UTERUS. 


247 


■ 

1 

■ 

^1 

L 

H 

R 

% 

1/ / 

« 

m 

r 

W 

m 

^K 

^ii 

9 

^E 

^^t^3ii 

^^ 

2 

Fig.  19. 


Fig.  20. 


are  maintained  by  the  advancing  curve  of  the  lumbar  spine 
in  the  true  axis  of  the  body. 

When  the  lumbar  spine  retreats, 
falling  on  a  line  behind  the  one  indi- 
cated in  Fig.  17,  the  distance  between 
the  sternum  and  pubes  is  shortened, 
and  as  a  result  the  abdominal  muscles 
relax  from  loss  of  tension.  The  organs 
in  the  abdomen  must  therefore  descend. 
Pelvic  obliquity  and  the  circulation  in 
the  pelvic  cavity  are  greatly  impaired. 

With  regard  to  uterine  displace- 
ments it  is  possible  that  the  primary 
cause  is  a  relaxation  of  spinal  and  ab- 
dominal muscles  and  consequent  unnat- 
ural gravitation. 

If  this  laxity  cause  uterine  displace- 
ment, the  means  of  cure  are  manifest ; 
and  Dewees  recommends  (Figs.  19,  20 
and  21)  the  natural  body  brace,  the 
combined  forces  of  which,  he  claims, 
all  tend  to  restore  normal  relationships 
and  positions. 

I  have  found  in  my  own  practice 
Fig.  21.  that  the  use  of  external  support  has  all 


248  MEDICAL  GYNECOLOGY. 

the  advantages  claimed  for  it  by  Dr.  Dewees.  This  I  have 
seen  while  employing  support  that  was  far  from  being  as 
suitable  and  well  adapted  as  his.  I  can  therefore  the  more 
strongly  recommend  the  method  of  Dr.  Dewees,  In  the  great 
majority  of  cases  the  hot-water  douche  employed  as  Dr. 
Emmet  directs  is  of  value.  The  water  should  be  medicated 
according  to  circumstances.  If  there  is  any  uterine  catarrh 
or  vaginitis,  as  well  as  relaxation  of  the  tissues,  astringent 
douches  are  not  effective. 

Displacements  of  the  uterus  give  rise  to  derangements  of 
the  nutritive  and  nervous  systems  similar  to  those  found  in 
chronic  inflammatory  affections  which  have  been  discussed. 
For  the  treatment  of  those  the  reader  is  referred  to  the  por- 
tion of  the  work  on  the  general  management  of  the  constitu- 
tional affections. 


CHAPTER  XXI. 

COlSrSTITUT^OlSrAL  DEEAT^GEMEISTTS  DUE  TO  OR  ACCOMPAlSrTIlSrG 
I]SrFLAMMATORY  DISEASES  OF  THE  SEXUAL  ORGANS,  AND 
THEIR  TREATMENT. 

In  the  subacute  or  catarrhal  forms  of  endometritis  there 
is  always  some  disturbance  of  the  nutritive  and  nervous  sys- 
tems. The  degree  of  disturbance  varies  according  to  the  gen- 
eral temperament  and  organization  of  the  patient.  Robust, 
phlegmatic  women  often  have  an  endometritis,  especially  if 
limited  to  the  cervix,  for  years  without  showing  any  marked 
impairment  of  the  general  health,  while  the  sensitive  woman 
—  the  sensitif  or  actif-sensitif — with  a  highly  developed 
nervous  system,  often  suffers  in  a  marked  degree.  Some- 
what similar  disturbances  may  also  come  from  ordinary  dis- 
placements of  the  uterus.  The  derangements  of  nutrition 
are,  as  a  rule,  doubtless  due,  first,  to  deranged  innervation, 
the  indigestion,  loss  of  appetite,  constipation,  and  ultimate 
malnutrition  being  evidently  produced  by  it  and  nothing 
else.  The  consciousness  of  some  disease  of  the  sexual  organs 
almost  invariably  gives  rise  to  a  certain  amount  of  anxiety 
and  leads  to  introspection,  which,  joined  with  the  peripheral 
irritation,  produces  the  general  disturbances  referred  to. 

These  impaired  conditions  of  nutrition  aggravate  or  tend 
to  prolong  the  local  lesions  which  stand  first  in  the  list  of  the 
causes  of  the  constitutional  disturbance.  Where  there  is  a 
profuse  leucorrhoeal  discharge  that  tends  to  depress  and  in- 
duce exhaustion  by  robbing  the  blood  of  highly  organized 
constituents,  the  nervous  disturbances  of  the  patient  are 
at  the  same  time  thereby  increased.     The  appetite  is  now 


250  MEDICAL  GYNECOLOaY, 

capricious,  then  abnormal  in  activity,  and  again  there  is  a 
dislike  for  food,  these  extremes  indicating  that  it  is  due  to 
deranged  innervation.  These  indications  of  disease  are  most 
marked  in  cases  of  corporeal  endometritis,  which  is  often 
attended  with  attacks  of  nausea  as  well  as  by  capricious 
appetite. 

When  these  symptoms  are  present,  while  the  tongue  is 
normal  in  ajDpearance  and  the  bowels  act  regularly,  it  is  evi- 
dent that  it  is  a  reflex  gastric  disturbance.  In  other  cases 
the  tongue  is  coated,  the  appetite  is  at  all  times  poor,  the 
bowels  are  usually  constipated,  and  the  eye  and  skin  fre- 
quently assume  a  yellow  tinge,  indicating  hepatic  torpor. 
There  is  usually  labored  digestion,  indicated  by  a  sense  of 
oppressive  fullness  after  eating,  flatulence,  distress,  discom- 
fort or  even  pain  in  the  stomach. 

In  purely  nervous  gastric  disturbances  attended  with  dys- 
pepsia there  is  very  often  either  hypersecretion  or  a  super- 
acid condition  of  hypermotility.  In  the  former,  there  is  very 
often  a  sense  of  burning  in  the  stomach  ;  in  the  latter,  acid 
eructations  are  noticeable.  Food  is  carried  out  of  the  stom- 
ach before  it  is  perfectly  digested,  and  hence  there  are  in- 
testinal flatulence  and  disturbance  of  the  bowels  shown  by 
alternating  attacks  of  constipation  and  diarrhoea.  This 
hypermotility  can  be  diagnosticated  by  giving  the  patient 
a  light  breakfast,  and  an  hour  or  so  afterward  washing  ont 
the  stomach  when  it  is  found  empty.  In  this  condition  the 
patients  very  often  have  an  abnormal  craving  for  food  an 
honr  or  two  after  having  taken  a  fairly  hearty  meal.  Again, 
the  reflex  nervous  effect  may  show  itself  by  depression  of  the 
motor  functions  of  the  stomach  and  intestines,  then  by  great 
sensitiveness  of  the  gastric  mucosa,  and  finally  by  a  dimin- 
ished secretion.  First  may  come  mere  atony,  when  ingesta 
are  delayed  in  their  passage  into  the  intestine.  The  stomach 
then  is  apt  to  become  dilated,  and  finally  what  are  known  as 
"  bilious  attacks  "  follow. 

Treatment. — The  treatment  of  the  nervous  dyspepsia,  as 
it  has  been  called  and  by  which  we  understand  impaired  or 


INFLAMMATORY  DISEASES  OP  THE  SEXUAL  ORGANS.      251 

variable  appetite,  indigestion,  and  deranged  innervation,  is  to 
remove  the  uterine  disease  whicli  gives  rise  to  it ;  but  while 
the  local  or  surgical  treatment  is  progressing  much  can  be 
done  to  add  to  the  comfort  of  the  patient  and  to  further 
and  hasten  the  recovery.  In  these  cases  I  have  found  that 
gastric  sedatives  give  the  most  marked  relief.  Moderate 
doses  of  subnitrate  of  bismuth  or  full  doses  of  oxalate  of 
cerium,  given  half  an  hour  or  an  hour  before,  meals,  sus- 
pended in, mucilage  of  acacia  and  cherry  laurel  water,  are 
often  beneficial,  especially  if  there  is  hypermotility.  When 
the  appetite  is  fair  and  digestion  is  not  hard  but  labored, 
pepsin,  charcoal,  and  the  bromide  of  soda,  taken  an  hour 
after  meals,  often  give  most  marked  relief.  When  this  does 
not,  I  give  it  before  meals,  and  find  that  occasionally  in  cer- 
tain cases  it  answers  better.  This  can  only  be  determined 
by  trial. 

With  deranged  digestion  due  to  imperfect  secretion,  and 
possibly  gastric  catarrh,  small  doses  of  calomel  for  a  day  or 
two,  followed  by  a  saline  laxative,  preferably  the  phosphate 
of  soda,  pave  the  way,  as  it  were,  for  further  treatment. 
If  the  tongue  remains  coated  and  there  is  evidence  of  a 
superacid  condition,  I  give  half  a  drachm  of  phosphate  of 
soda  an  hour  or  thereabouts  before  meals,  well  diluted,  and 
then  after  meals  administer  pepsin  diastase  and  small  doses 
of  nux  vomica  with  some  aromatic.  Should  these  not  keep 
the  bowels  regular,  I  increase  the  quantity  of  phosphate  of 
soda ;  and  if  this  fails,  I  then  give  a  combination  of  two 
grains  of  ox  gall  with  moderate  doses  of  pepsin,  and  one 
eighth  or  one  tenth  of  a  grain  of  nux  vomica  in  a  pill  before 
meals  and  pancreatin  after  meals. 

In  obstinate  cases  of  constipation  I  add  to  the  ox  gall  one 
grain  of  quinine,  one  tenth  grain  nux  vomica,  one  tenth  grain 
belladonna,  and  one  or  a  half  grain  of  compound  extract  of 
colocynth,  with  a  grain  of  ipecac.  This  in  pill  form  before 
meals  answers  very  well.  In  patients  that  are  somewhat  ro- 
bust and  not  especially  inclined  to  flatulence  I  regulate  the 
bowels  by  giving  a  dose  of  some  of  the  mineral  waters,  as 


252  MEDICAL  GYNECOLOGY. 

Eubinat  Llorach.  To  increase  the  appetite  I  give  the  tinc- 
ture of  calumba,  well  diluted,  before  meals,  or,  in  many 
cases  what  is  better,  when  the  stomach  is  irritable,  infusion 
of  the  same.  After  meals  some  of  the  digestives,  like  pep- 
sin, pancreatin,  and  diastase,  answer  excellently. 

The  treatment  of  these  cases  which  begin  with  atony 
should  be  rest  in  bed,  a  change  of  climate  and  surroundings 
when  possible,  electricity  to  restore  tone  to  the  muscular 
wall  of  the  stomach  and  washing  out  that  organ  ;  but  this 
latter  should  not  be  done  too  frequently.  The  diet  is  any- 
thing, in  reason,  the  patient  can  digest. 

Mercury,  iron,  strychnine,  bismuth,  and  hydrochloric  acid 
are  the  best  drugs  in  these  cases  ;  and  where  the  "  blue  pill  " 
is  too  powerful,  Hunyadi  or  Friedrichshall  water  can  be 
given,  hot,  in  the  morning.  Sodium  and  magnesium  aperi- 
ents are  excellent  all  through  this  plan  of  treatment. 

The  Nervous  Disturbances. — The  condition  of  the  nervous  sys- 
tem in  uterine  disease  differs  according  to  the  stage  and  the 
duration  of  the  affection.  At  first  comes  occasional  headache, 
discomfort,  or  a  disagreeable  feeling  in  the  head  ;  then  there 
is  a  sensation  of  weight  on  top  of  the  head,  with  lack  of  co- 
ordination of  thought  to  a  very  limited  extent,  and,  follow- 
ing these,  usually  in  cases  that  have  not  existed  for  a  great 
length  of  time,  are  irritability,  restlessness,  disposition  at 
times  to  become  depressed,  with  sleeplessness,  difficulty  in 
getting  asleep,  or  waking  up  after  a  short  repose. 

In  addition  to  the  local  treatment,  especially  the  sedative 
effect  of  the  hot  vaginal  douche,  bromides  answer  well ;  a 
dose  in  the  afternoon  and  another  at  bedtime,  suflSciently 
large  to  secure  a  quiet  night's  rest,  are  all  that  is  necessary. 
It  is  perhaps  the  most  satisfactory  of  all  the  sedatives  that  I 
can  recommend.  Valerian,  lavender,  and  their  allies,  which 
have  been  highly  recommended,  I  have  found  in  most  of 
my  cases  to  aggravate  the  difiiculty,  and  prove  worse  than 
useless.  I  am  obliged  to  rely  upon  bromides.  When  there 
is  evident  nervous  exhaustion,  then  nerve  tonics  as  well  as 
sedatives  are  required.      The  best  of  these  I  find  to  be  a 


INFLAMMATOHY  DISEASES  OP  THE  SEXUAL  ORGANS.      253 

combination  of  strychnine  and  belladonna  in  small  doses, 
with  camphor  and  lupulin  as  a  sedative.  These  are  given, 
as  the  bromides  are,  in  the  afternoon  and  at  bedtime. 
In  these  cases  bromides  sometimes  must  be  prescribed,  espe- 
cially if  there  is  difficulty  in  maintaining  prolonged  sleep ; 
but  I  find  it  necessary  in  such  cases  to  give  nux  vomica 
v^^ith  the  bromide,  and  I  usually  add  small  doses  of  ar- 
senic. 

The  use  of  baths  is  advisable,  beginning  with  a  tepid  or 
warm  bath,  and  the  temperature  is  gradually  lowered  until 
it  becomes  somewhat  of  a  stimulant  or  tonic.  All  the  above 
applies  to  cases  in  which  the  nervous  disturbance  is  not  de- 
cidedly marked.  I  shall  refer  again  to  the  treatment  of  neu- 
rasthenia while  discussing  the  constitutional  treatment  of  dis- 
eases of  the  ovaries  and  tubes. 

Rest  in  the  recumbent  position  is  of  great  influence  in  re- 
lieving all  forms  of  uterine  inflammatory  diseases.  In  the 
subacute  form  continual  rest  in  bed  is  not  necessary ;  it  is 
better  that  the  patient  should  have  short  periods  of  exercise 
alternating  with  periods  of  rest  during  the  day,  and  abun- 
dant rest  and  sleep  at  night.  While  in  the  recumbent  posi- 
tion the  pelvis  is  elevated  and  a  certain  amount  of  relief 
from  hyperaimia  is  obtained.  In  cases  of  uterine  disease  as- 
sociated with  anaemia  and  sleeplessness  Dr.  Emmet  found 
great  improvement  by  giving  the  patient  a  low  pillow  and 
elevating  the  foot  of  the  bed.  The  knee-chest  position  as- 
sumed for  a  few  minutes  in  the  morning  before  rising,  and 
again  before  going  to  sleep  after  retiring,  gives  relief,  and 
this  may  be  practiced  several  times  during  the  day  also  with 
benefit.  The  use  of  baths  adapted  to  the  condition  of  the 
patient,  so  as  to  keep  the  skin  in  good  condition  and  stimu- 
late ultimate  nutrition,  is  beneficial.  In  the  more  acute 
forms  of  metritis,  especially  the  septic,  and  in  certain  cases 
of  subinvolution,  continuous  rest  in  bed  is  very  necessary ; 
here  massage  will  keep  up  the  general  nutrition  and  mus- 
cular strength.  Electricity,  too  —  general  faradization  and 
galvanization  —  are  minor  aids  which  may  be  employed  in 


254  MEDICAL  GYNECOLOGY. 

those  severer  cases  in  wliicli  tlie  nutritive  and  nervous  sys- 
tems are  involved  to  a  considerable  degree. 

In  regard  to  tlie  use  of  remedies  given  to  act  on  the  gen- 
eral organization,  primarily  and  indirectly  upon  the  uterus, 
it  must  be  confessed  that  we  have  none  that  specifically  act 
on  that  organ  excepting,  perhaps,  ergot  and  hydrastis  cana- 
densis. Ergot  I  have  long  ago  abandoned.  I  rely  upon  hy- 
drastis canadensis,  which  has  some  value  in  cases  of  subinvo- 
lution with  endometritis  and  menorrhagia,  wherein  I  have 
found  that  five  or  ten  drops  of  it  before  meals  and  at  bedtime 
appear  to  exercise  a  decided  influence  in  lessening  the  hyperse- 
mia.  All  other  remedies,  if  they  affect  the  uterus  at  all,  do  so 
by  fii'st  favorably  infiuencing  the  general  nutrition.  As  a  rule, 
restoratives  are  useful.  Proper  food,  of  course,  is  all-impor- 
tant, and  as  most  cases  are  asthenic,  they  require  a  good  nour- 
ishing diet.  This  should  be  largely  a  vegetable  one,  with 
fruit,  milk,  and,  if  indicated,  the  peptonized  foods.  When 
the  general  nutrition  is  fair  I  get  better  results  by  keeping 
them  on  a  rather  meager  diet,  with  a  little  animal  food  not 
more  than  once  a  day,  because  a  little  food  well  digested  is 
more  conducive  to  normal  nutrition  in  patients  who  are 
unable  to  take  active  exercise  than  the  more  easily  digested 
and  stimulating  of  foods,  especially  animal. 


CHAPTER   XXII. 

^DISEASES   OF   THE   EXTERISTAL   GENITALS. 

The  great  majority  of  the  inflammatory  diseases  of  the 
external  organs  of  generation  that  come  under  the  notice  of 
the  physician  are  produced  by  want  of  care  in  keeping  the 
parts  clean — constitutional  diseases,  such  as  the  eruptive 
fevers,  and  specific  and  septic  infection.  Inflammation  of 
these  organs  occurs  at  all  ages,  but  varies  in  character  at 
the  different  periods  of  life. 

Young  children  are,  of  course,  most  exposed  to  the  vul- 
vitis of  the  eruptive  fevers,  and  to  that  which  occurs  under 
tubercular  conditions.  In  middle  life  the  septic  and  spe- 
cific varieties  are  most  frequently  seen.  In  the  aged  there 
are  inflammatory  affections  of  the  vulva  that  are  peculiar, 
and  will  be  spoken  of  in  connection  with  the  diseases  of 
old  age. 

It  is  evident,  from  the  nature  of  the  causation  of  these 
affections,  that  much  can  be  done  in  the  way  of  prevention, 
and  this  subject  is,  I  believe,  often  neglected  at  all  seasons 
of  life  and  among  all  kinds  and  conditions  of  women. 

In  little  children  the  genitals  are  either  neglected  alto- 
gether or  bathed  in  such  an  imperfect  and  rough  way  that 
little  benefit  is  derived — in  fact,  harm  is  often  done.  The 
proper  way  to  bathe  these  parts  is  to  take  borax  and  water 
or  soap  and  water,  and  let  it  flow  from  a  fountain  sponge 
over  the  surface,  being  careful  to  clean  out  all  secretions  in 
the  folds  of  the  mucous  membrane  and  skin.  Care  should 
be  taken  not  to  have  the  fountain  pressure  too  strong,  or  to 
throw  the  stream  directly  against  the  vulva.     Inattention  to 


256  MEDICAL  GYNECOLOGY. 

these  points  may  permit  the  water  to  enter  the  vagina  and 
carry  with  it  offending  matter. 

The  parts  when  cleansed  should  be  dried  with  absorbent 
cotton  pressed  gently  against  the  surfaces,  avoiding  all  rub- 
bing. Towels  and  sponges  should  never  be  employed.  It  is 
infinitely  safer  and  more  economical  to  use  cotton  and  then 
throw  it  away.  This  attention  to  bathing  should  be  given 
by  nurse,  mother,  or  attendant,  until  the  girl  is  old  enough 
to  care  properly  for  herself,  which  time  is  about  the  period 
of  puberty. 

The  prepuce  should  always  receive  attention.  It  is  as 
often  adherent  in  girls  as  in  boys,  and  the  evil  effects  as  pro- 
nounced in  one  case  as  in  the  other.  The  physician  should 
see  that  any  such  defects  or  lesions  are  overcome,  and  adhe- 
sions separated.  This  is  all  that  is  necessary  to  relieve  the 
irritation  that  is  generally  caused  by  them,  and  it  also  makes 
cleanliness  possible.  In  middle  life  the  same  bathing  should 
be  employed,  particularly  after  menstruation.  In  those  who 
are  subject  to  a  free  secretion  of  the  glands  of  the  vulva — 
especially  if  such  secretion  is  irritating  and  offensive — fre- 
quent ablutions  are  necessary. 

Much  might  be  said  in  regard  to  those  unfortunate  wives 
who  are  obliged  to  live  with  diseased  men,  but  I  may  briefly 
say  that  a  vaginal  douche  and  thorough  bathing  of  the  vulva 
before  and  after  exposure  to  contagion  will  do  much  toward 
prevention. 

Vulvitis. — In  the  cases  that  have  come  under  my  observa- 
tion the  inflammation  of  the  vulva  has  been  secondary  to  and 
caused  by  some  pre-existing  affection,  except  the  vulvitis  of 
children  and  the  specific  forms. 

Uncomplicated  vulvitis — nonspecific — may  occur  in  several 
ways — as  a  simple  erythema,  a  purulent  inflammation,  or  as  a 
follicular  inflammation.  The  erythematous  variety  is  char- 
acterized by  a  general  redness  of  the  vulva,  limited  to  the 
mucous  surfaces,  though  sometimes  it  extends  to  the  skin. 
It  is  usually  transient,  occasionally  passing  away  without 
much  treatment.     The  purulent  form  is  more  defined.     The 


DISEASES  OF  THE  EXTERNAL   GENITALS.  257 

parts  are  red  and  covered  with  a  copious  formation  of  pus, 
and  the  epithelium  rapidly  exfoliates,  leaving  a  raw-looking 
surface.  Occasionally  small  patches  of  ulceration  are  to  be 
seen,  but  these,  as  a  rule,  are  neither  large  nor  deep. 

In  follicular  vulvitis  the  mucous  membrane  generally  is 
not  changed  in  appearance  ;  sometimes  it  has  a  deeper  color, 
but  the  whole  surface  is  studded  with  small  red  points  which, 
on  close  investigation,  are  found  to  be  the  orifices  of  mucous 
follicles  ;  ,the  size  and  number  of  these  inflamed  spots  vary  in 
different  cases.  This  form  occurs  most  frequently  in  aged 
women.  In  this  and  in  the  purulent  form  the  discharge  is 
increased  by  a  free  secretion  from  the  mucous  and  sebaceous 
glands,  and  this  gives  rise  to  a  very  disagreeable  odor.  There 
is  also  in  most  cases  considerable  pruritus. 

Causation. — Evidently  the  strumous  diathesis  and  the 
lymphatic  temperament  predispose  to  it.  All  the  cases  which 
I  have  seen,  that  could  not  be  traced  to  some  pre-existing  or 
specific  cause,  have  been  in  strumous  or  phlegmatic  women 
and  children.  The  exciting  causes  are  want  of  cleanliness, 
septic  and  specific  infection,  and  constitutional  diseases,  such 
as  the  eruptive  fevers ;  dysentery,  ascarides,  and  erythema 
intertrigo  are  occasional  causes.  Age  also  has  its  influence. 
The  purulent  variety  occurs  in  children,  while  the  follicular 
form  occurs  most  frequently  in  the  aged. 

Symptomatology. — The  symptoms  are  suggestive  only, 
not  diagnostic.  The  discharge,  heat,  tenderness,  and  pruritus 
are  the  chief  symptoms,  but  they  all  recur  when  the  vulvitis 
is  associated  with  vaginitis,  and  similar  phenomena  are  noted 
in  many  of  the  eruptive  diseases  of  the  vulva. 

Physical  Signs. — These  are  the  same  as  those  presented 
by  inflammation  of  mucous  membranes  generally,  and  hence 
need  not  be  given  here. 

Diagnosis.- — This  is  made  by  inspection  and  a  careful 
exclusion  of  all  other  affections,  such  as  vaginitis,  eruptive, 
specific,  or  malignant  disease.  To  determine  whether  the 
vagina  is  involved  or  not  is  important,  but  in  children  rather 
difficult.    Inspection  shows  whether  the  inflammation  extends 


258  MEDICAL  GYNECOLOGY. 

above  the  hymen  ;  and  that,  and  the  extreme  quantity  of  the 
discharge,  may  suggest  vaginitis.  More  definite  evidence  is 
obtained  by  washing  the  vulva  clean  and  applying  cotton  at 
the  introitus  which  will  catch  and  show  the  discharge  from 
the  vagina,  if  there  is  any. 

Treatment. — The  chief  objects  in  the  management  of  vul- 
vitis are  to  keep  the  parts  clean  and  to  separate  the  inflamed 
surfaces.  This  is  difiicult  to  do  in  children,  hence  the  com- 
plete relief  of  this  affection  in  the  young  is  not  by  any  means 
easily  effected. 

In  vulvitis  of  women  I  have  of  late  years  relied  upon  fre- 
quent washing  with  a  solution  of  borax  or  boric  acid,  and 
then,  after  drying  the  parts,  applying  thoroughly  a  dry  pow- 
der of  subnitrate  of  bismuth,  oxide  of  zinc,  or  iodoform  der- 
matol.  This  method  answers  very  well  if  the  patient  has  a 
nurse  who  can  carefully  employ  the  treatment.  Equally  good 
results  have  been  obtained  by  applying  to  the  parts,  after 
bathing  thoroughly,  either  of  the  following  solutions :  sul- 
phate of  zinc  four  grains,  fluid  extract  of  hydrastis  canaden- 
sis one  ounce,  and  water  three  ounces ;  or  nitrate  of  silver 
and  water  one  ounce.  After  applying  either  of  these  lotions 
a  small  pledget  of  absorbent  cotton  should  be  placed  between 
the  labia,  to  keep  the  surfaces  apart  and  to  absorb  the  puru- 
lent discharge. 

Vulvitis  is  most  difficult  to  manage  in  little  girls  and 
young,  unmarried  women,  but,  with  proper  and  persistent 
treatment  correctly  carried  out,  success  may  be  positively 
assured ;  otherwise  the  disease  is  most  obstinate.  The  parts 
should  be  thoroughly  bathed  and  cleansed  in  the  way  de- 
scribed in  the  beginning  of  this  article — three  or  four  times 
in  the  twenty-four  hours,  and,  after  each  cleansing,  one  to 
three  grains  of  sulphate  of  zinc  to  the  ounce  of  water  should 
be  applied,  preferably  with  an  atomizer.  The  parts  are  then 
dried,  and  absorbent  cotton  placed  between  the  inflamed 
labia,  in  case  the  patient  is  old  enough  to  permit  it  to  re- 
main. In  children,  in  place  of  the  cotton,  I  use  dermatol 
or  prepared  chalk  and  bismuth,  applied  with  McKesson  and 


DISEASES  OF  THE  EXTERNAL  GENITALS.  259 

Robbins's  applicator.  In  the  same  way  I  use  iodoform  in  fine 
powder,  which  is  most  effective,  but  objected  to  on  account 
of  its  odor. 

When  there  is  extreme  tenderness  I  use  with  the  atomizer 
a  two-per-cent  solution  of  cocaine  during  the  first  day  or  two 
before  each  dressing  or  application  of  the  zinc  solution. 

When,  in  children,  the  infiammation  extends  from  the 
vulva  to  the  vagina,  the  disease  is  difiicult  to  manage.  The 
treatment, of  the  vulva  ought  to  be  the  same,  but  vaginal 
douches  should  be  used.  After  thoroughly  washing  the 
vulva,  a  soft-rubber  catheter  (Tiemann's  velvet-eyed)  should 
be  attached  to  a  fountain  syringe  and  passed  high  up  into 
the  vagina,  and  a  thorough  douche  of  boiled  water  applied. 
After  this,  a  mild  (one  grain  to  the  ounce)  solution  of  sul- 
phate of  zinc  ought  to  be  injected  or  instilled  with  the  same 
syringe  and  before  withdrawing  the  catheter.  The  patient 
has  to  be  kept  in  bed,  or  at  rest,  and  under  the  constant  care 
of  a  competent  nurse.  There  is  so  much  tenderness  that  a 
mild  solution  of  cocaine  has  to  be  applied  to  the  vulva  be- 
fore using  the  vaginal  injection. 

It  occasionally  happens  that  vulvitis  appears  during  scar- 
let fever,  measles,  and  diphtheria,  and  although  in  the  two 
former  affections  the  inflammation  is  of  the  erythematous 
variety  and  passes  off,  it  may  become  permanent — i.  e.,  sup- 
purative and  persistent.  The  physician  should  carefully 
watch  for  the  first  indication  of  the  affection,  and  promptly 
institute  treatment.  The  results  in  neglected  cases  are  often 
very  disastrous. 

The  treatment  already  given  answers  all  indications  in  the 
ordinary  cases  occurring  in  connection  with  non-malignant 
scarlatina  and  rubeola. 

In  diphtheria  I  have  found  the  bichloride  of  mercury  to  be 
especially  efliicient.  Years  ago  I  had  an  experience  which 
was  profitable  in  this  respect.  I  saw  a  case  of  puerperal  sep- 
sis in  which  there  was  a  diphtheritic  exudation  on  the  cervix 
uteri  and  vulva.  Carbolic  acid  was  then  a  favorite  germicide, 
and  was  freely  used  by  the  attending  physician.    The  patient 


260  MEDICAL   GYNECOLOGY. 

died.  Two  years  afterward  I  saw  in  the  same  house  and 
room  a  patient  in  a  similar  condition,  except  that  the  diph- 
theria of  the  vulva  was  more  prominent.  The  attending 
physician — not  the  one  in  charge  of  the  former  case — was 
using  bichloride  of  mercury  (one  in  two  thousand)  as  a  wash 
for  the  parts  involved.  The  patient  recovered.  These  cases 
were  seen  before  the  local  use  of  mercurial  salts  in  diphtheria 
was  employed  as  successfully  as  it  now  is.  These  facts  have 
persuaded  me  to  use  the  bichloride  in  all  diphtheritic  and 
diphtheroid  forms  of  vulvitis.  One  part  in  four  thousand  I 
prefer  to  a  stronger  solution,  and  I  can  safely  use  it  oftener, 
which  I  do — at  the  outset  of  the  treatment — about  once  an 
hour. 

In  cases  due  to  rectitis,  ascarides,  and  malignant  or  specific 
diseases  of  the  uterus  and  vagina  the  treatment  already  given 
is  employed  in  connection  with  the  management  of  the  pri- 
mary affection  causing  the  vulvitis. 

Pruritus  of  the  Vulva. — The  name  indicates  that  this  is  a 
symptom,  not  a  disease,  but  it  occurs  occasionally  when  the 
cause  can  not  be  discovered,  and  hence  it  has  long  been 
customary  to  treat  it  as  a  distinct  affection. 

The  pathology  is  exceedingly  variable.  In  one  case  there 
is  found  a  slight  congestion,  approaching  an  erythematous 
inflammation,  due  to  some  irritating  discharge  from  the 
vagina,  urethra,  or  endometrium.  In  another  there  is  a  con- 
dition which  is  like  an  eczema ;  this  is  produced  by  saccha- 
rine urine.  In  others  it  appears  to  be  due  to  reflex  nervous 
derangement  caused  by  some  rectal  disease ;  and  there  still 
remain  many  cases  which,  in  the  absence  of  any  apparent 
cause,  are  attributed  to  some  purely  nerve  affection  or  local 
neurosis  ;  and,  lastly,  there  is  a  dry  condition  of  the  mucous 
membrane  and  skin,  which  appear  pale  in  patches  and  cov- 
ered with  a  coating  of  dead  epithelium. 

There  are  usually  in  this  condition  a  number  of  superficial 
fissures,  which  are  red,  moist,  and  sensitive.  It  has  been 
said  that  the  latter  condition  is  due  to  some  parasite  or 
pathogenic  germ.      This  is  very  probable ;   but  I  regret  to 


DISEASES  OP  THE  EXTERNAL   GENITALS.  261 

say  that  I  have  not  taken  the  time  to  verify  or  correct  this 
statement. 

Pruritus  occurs  in  its  most  severe  form  about  the  meno- 
pause, especially  that  variety  which  is  not  definitely  discov- 
ered to  be  due  to  any  of  the  systemic  or  local  diseases  v^hich 
are  knov^u  to  cause  it.  Although  it  is  limited  ordinarily  to 
the  vulva,  it  may  extend  to  the  lov^er  portion  of  the  vagina, 
anus,  and  integument  adjoining  the  mucous  membrane. 

From  pertain  observations  that  I  have  made,  I  believe  that 
the  true  lesions  in  the  severer  cases  (not  otherwise  accounted 
for)  are  degeneration  of  the  capillary  vessels  and  retardation 
of  exfoliation  of  the  old  epithelium.  While  I  have  found 
these  conditions  present,  I  have  not  made  microscopical 
examinations  sufficient  to  demonstrate  fully  the  change  of 
structure,  neither  have  I  made  bacterial  investigations  to 
prove  the  presence  or  absence  of  germs  that  might  be  causa- 
tive factors. 

Symptomatology. — The  patient  notices  an  itching  of  the 
parts  affected,  which  is  at  first  relieved  by  scratching  or  rub- 
bing, but  later  this  relief  is  but  temporary,  and  the  friction 
aggravates  the  original  trouble.  The  tickling,  sharp  stinging 
and  burning  sensations  become  at  times  intolerable,  and  the 
patient  is  debarred  from  the  society  of  her  friends.  In  some 
instances  the  annoyance  and  suffering  are  increased  at  night, 
and  in  order  to  obtain  sleep,  hypnotics  have  to  be  admin- 
istered. 

Pliy steal  Signs. — The  signs  vary  according  to  the  cause  of 
the  irritation,  and  are  described  above  in  speaking  of  the 
pathology.  In  some  cases  there  are  no  definite  signs  present. 
A  due  appreciation  of  these  facts  is  necessary  for  the  insti- 
1;ution  of  proper  treatment. 

Causation. — The  causes  are  many  and  varied,  as  has  been 
foreshadowed  by  the  remarks  regarding  pathology.  Pruritus 
being  only  a  symptom  of  many  affections,  one  has  only  to 
mention  the  diseases  with  which  it  is  associated  to  fill  out 
the  list  of  causes.  This  is  far  from  being  satisfactory,  as  it 
leaves  the  direct  cause  of  the  disease  unexplained. 


262  MEDICAL  GYNECOLOGY 

The  possible  causes  (whicli  may  be  known  as  certain  dis- 
eases in  the  future,  when  better  understood)  are  an  undeter- 
mined parasite  or  germ  and  a  malnutrition  and  degeneration 
of  the  capillary  vessels  such  as  I  have  specially  referred  to. 
Then  come  the  diseases  with  which  it  most  frequently  occurs, 
diabetes  standing  first  in  the  list.  Saccharine  urine  surely 
causes  pruritus  of  the  parts  with  which  it  comes  in  contact,  a 
fact  worth  remembering,  because  it  is  the  most  definite  thing 
known  about  this  subject.  ISText  in  order  are  all  discharges 
from  the  vagina  or  urethra  that  are  of  an  irritating  nature. 
The  discharges  of  vaginitis,  corporeal  endometritis,  cancer  of 
the  uterus,  and  urethritis  are  said  to  be  especially  active  in 
causative  effect. 

According  to  my  observation,  rectal  diseases,  such  as  fis- 
sure or  ascarides,  cause  pruritus,  but  not  of  the  severest  order. 
Certain  conditions  or  affections  of  the  nerves,  general  or  local, 
are  inferred  to  cause  this  trouble,  but  I  have  not  found  any- 
thing definite  upon  the  subject  either  in  the  works  of  others 
or  in  my  own  practice. 

Treatment. — The  first  object  in  the  management  of  pruritus 
is  to  cure  the  disease  which  promotes  it ;  or,  if  that  is  im^Dos- 
sible,  to  protect  the  vulva  from  the  discharge,  which  is  the 
offending  agent.  Discharges  from  the  uterus  or  vagina  can 
usually  be  arrested,  except  in  cancer.  In  that  affection  when 
it  causes  a  severe  pruritus  or  vulvitis  I  use  a  vaginal  douche 
of  zinc  or  carbolic  and  acetic  acid  and  place  a  tampon  of  cot- 
ton in  the  vulva  and  lower  part  of  the  vagina.  This  is  often 
enough  to  keep  the  vulva  protected  from  the  discharge,  and 
meantime  such  applications  as  are  indicated  should  be  made 
to  the  organ  to  cure  the  immediate  irritation  and  relieve  the 
pruritus. 

In  the  treatment  of  the  pruritus  of  diabetes  I  direct  the 
patient  to  separate  the  labia  while  urinating,  to  keep  the 
urine  from  touching  them,  and  then  to  dry  the  meatus  with 
cotton.  The  parts  are  still  further  protected  from  the  urine 
by  applying  thoroughly  to  the  vulva  boric  ointment  (Lister's) 
or  stearate  of  zinc.     This  manner  of  treatment  gives  most 


DISEASES  OF  THE  EXTERNAL  GENITALS.  263 

satisfactory  results  in  diabetic  pruritus — as  I  call  it — but  tlie 
treatment  must  be  faithfully  and  continuously  employed. 

Yery  satisfactory  results  can  be  obtained  in  treating  cases 
where  the  pruritus  is  caused  by  some  appreciable  disease, 
general  or  local.  The  greatest  difficulties  are  experienced  in 
managing  that  form  of  pruritus  which  occurs  without  any 
lesion  of  structure  or  accompanying  well-understood  affec- 
tions to  account  for  it.  In  these  cases,  as  already  stated,  the 
skin  is  bleached,  in  spots  appearing  whiter  than  the  normal 
skin  ;  it  has  also  lost  the  normal  elasticity,  while  to  the  touch 
it  seems  harder  and  less  flexible. 

Many  of  these  cases  prove  to  be  incurable,  and  in  some  it 
is  not  possible  to  give  the  patient  complete  relief  by  any  local 
treatment.  This  has  led  to  the  use  of  a  great  variety  of 
agents,  but  none  of  them  have  proved  to  be  at  all  times  reli- 
able. 

The  remedies  that  have  given  the  best  results  in  my  prac- 
tice are  bichloride  of  mercury  (one  grain  to  the  ounce)  and 
emulsion  of  bitter  almonds,  to  be  applied  to  the  parts  affected 
two  or  three  times  a  day  ;  a  powder  of  one  grain  of  mor- 
phine to  two  grains  of  chalk  applied  night  and  morning ; 
equal  parts  of  tincture  of  opium,  iodine,  and  aconite,  and 
eight  per  cent  of  carbolic  acid  applied  once  a  day.  All  these 
have  been  tried  and  have  proved  serviceable  to  some  extent, 
but  there  are  cases  which  resist  all  these  remedies. 

The  bichloride  of  mercury,  used  alone,  has  been  of  the 
most  service  in  the  largest  number  of  cases.  Where  it  fails  I 
have  used  a  solution  of  iodoform  in  ether,  applied  by  means 
of  an  atomizer,  and  by  using  strong  air  pressure  the  solution 
is  forced  into  all  the  folds  of  the  mucous  membrane.  The 
ether  soon  evaporates  and  leaves  a  fine  coating  of  the  iodo- 
form over  the  whole  surface.  This  nearly  always  relieves, 
and  if  applied  frequently  is  curative  in  some  cases. 

I  have  also  used  carbolic  acid  and  tincture  of  iodine,  equal 
parts,  and  this  nearly  always  gives  relief  for  a  day  or  more. 
In  the  following  case  this  application  relieved  the  pruritus 
permanently : 


264  MEDICAL  GYNECOLOGY. 

The  patient  had  passed  the  menopause,  and,  although  she 
had  not  borne  children,  her  health  had  always  been  good. 
Dr.  Fordyce  Barker,  whom  she  consulted,  sent  her  to  me, 
telling  her  at  the  same  time  that  I  could  not  cure  her,  but 
would  give  her  as  much  relief  as  possible.  I  tried  the  usual 
remedies,  with  no  benefit ;  then  used  the  carbolic  acid  and 
iodine,  but  found  it  difficult  to  apply  to  all  the  irregularities 
of  the  surface.  It  was  apiDlied  with  the  atomizer,  using  a  high 
pressure  so  that  the  solution  was  forced  into  the  tissues,  and 
a  deeper  effect  obtained  than  I  had  expected.  The  first  effect 
was  sharp  pain,  followed  very  soon  by  relief  from  the  itching 
and  numbness  of  the  parts  ;  in  short,  the  anaesthetic  effect  of 
the  carbolic  acid  was  obtained  in  a  marked  degree.  Follow- 
ing this  there  were  great  irritation  and  pain ;  the  epithelial 
layers  of  the  skin  and  mucous  membrane  came  off  as  if  they 
had  been  blistered,  and  there  was  much  sensitiveness.  But 
even  when  in  the  most  pain  the  patient  said  she  suffered  far 
less  than  from  the  itching.  When  she  recovered  from  the 
treatment  the  tickling  sensation  did  not  return  for  several 
weeks,  and  then  only  in  a  slight  degree.  I  made  the  same 
application  once  again  to  several  spots  where  there  was  se- 
vere itching,  being  careful  not  to  cover  more  than  a  very 
small  area.  It  was  not  necessary  to  apply  the  remedy  a  third 
time.  She  completely  recovered  and  remained  well  for  one 
year  at  least,  and  I  presume  had  no  relapse,  as  I  heard  no 
more  from  her. 

Electricity  has  been  used  in  all  forms  of  this  affection,  but 
without  much  benefit  being  derived  from  it  as  far  as  I  know. 

When  the  vulva  is  involved  in  a  general  pruritus  caused 
by  hepatic  disease  and  jaundice,  nitric  acid  or  hydrochloric 
acid  (one  ounce  in  thirty  or  forty  gallons  of  water),  used  as  a 
general  bath,  is  valuable.  To  relieve  the  suffering,  especially 
at  night,  cocaine  and  menthol,  benzoinole  and  menthol,  mor- 
phine and  bismuth — used  in  powder — and  dermatol,  have  all 
been  found  useful,  but  the  benefit  is  temporary. 

Bathing  with  hot  water  and  borax  does  well  in  some  cases. 
Salicylic  acid,  five  parts,  lanolin,  ninety-five  parts,  make  a 


DISEASES  OF  THE  EXTERNAL   GENITALS.  265 

useful  ointment.  Scanzoni  recommended  chloroform  3  ij, 
oleiamygdale  3  ij.  Chloral  hydrate,  camphorse,  aa  3  ss.,  and 
ungt.  aquse  rosse  3  ij,  is  a  most  valuable  application  when  it 
does  not  cause  smarting. 

Finally,  I  have  used  ichthyol,  gr.  xx,  to  lanolin,  §  ij, 
MAhich  has  in  some  cases  a  curative  as  well  as  a  quieting 
effect.  The  reason  for  giving  so  many  remedies  is,  that  by 
trying  a  number,  one  may  be  of  service  in  certain  cases  even 
if  useless ,  in  others.  In  this  disease  the  old  saying  that 
what  helps  one  may  hurt  another — or  at  least  not  benefit — 
proves  true. 

Hyperaesthesia  of  the  Vulva. — This  affection  is  most  frequently 
seen  among  young  married,  sterile  women,  and  after  the 
menopause.  It  has  been  known  by  the  name  of  irritable  hy- 
men ;  but  the  hymen  is  not  always  the  part  involved.  In  fact, 
there  are  two  forms  that  I  have  seen.  In  the  one  there  is  a 
general  tenderness  about  the  vulva  without  any  appearances 
to  indicate  disease  or  change  of  structure ;  the  other  is 
characterized  by  a  slight  thickening  of  the  hymen  and  pro- 
liferation of  the  epithelium,  which  give  a  pale,  papillary, 
ragged  appearance  to  the  margin  of  the  hymen.  In  the  lat- 
ter variety  the  hymen  is  alone  involved. 

When  seen  at  the  menopause  the  disease  presents  no 
change  of  structure  as  far  as  one  can  judge  from  appear- 
ances, and  should  be  clearly  distinguished  from  vaginismus 
and  the  tenderness  which  is  caused  by  inflammatory  affec- 
tions, especially  neoplasms  of  the  meatus  urinarius.  It  is 
characterized  by  a  supersensitiveness  of  the  parts,  shown  by 
extreme  tenderness  to  the  touch.  Patients  sometimes  delay 
seeking  advice,  from  dread  of  an  examination.  Pain  is  not 
often  present,  only  tenderness,  which  is  the  only  symptom 
noticed  in  bathing  and  wearing  a  protector  during  menstru- 
ation, and  in  dyspareunia. 

The  diagnosis  is  made  by  excluding  all  inflammatory 
affections,  scar-tissiie,  and  diseases  of  the  rectum,  such  as 
fissure  which  is  sometimes  attended  by  tenderness  of  the 
vulva. 


266  MEDICAL  GYNECOLOGY. 

Causation. — Nervous  women  may  be  predisposed  to  this 
affection,  but  I  have  only  seen  one  case  in  which  the  local 
trouble  ai)peared  to  be  a  part  of  a  general  neurotic  state  or 
general  hypergesthesia.  Marriage  with  incomplete  coitus  ap- 
pears to  be  the  cause  in  many ;  masturbation  may  also  cause 
it,  but  of  this  I  am  not  sure.  At  the  menopause  it  appears 
to  be  due  to  an  irregular  atrophy  or  degeneration  and  mal- 
nutrition of  the  nerve  and  other  tissues. 

Treatment. — When  the  hymen  is  present  and  there  is 
hyperplasia  as  referred  to,  the  treatment  consists  in  the 
removal  of  the  peculiar  and  especially  tender  tissue.  The 
reader  is  referred  to  works  on  surgery  for  a  discussion  of 
this  subject.  The  medical  treatment  which  is  indicated,  and 
which  gives  relief  in  most  cases,  consists  in  temporarily  re- 
lieving the  tenderness  by  the  use  of  cocaine — a  two-per-cent 
solution  aj)plied  with  the  atomizer,  or  by  saturating  a  piece  of 
cotton  ;  the  latter  method  keeps  up  the  effect  longer.  Men- 
thol and  benzoinol  is  of  marked  value  in  the  cases  that  occur 
at  the  menopause  when  there  is  dryness  as  well  as  tenderness 
of  the  mucous  membrane.  The  use  of  cocaine  often  relieves 
the  dyspareunia ;  and  if  gestation  takes  place  the  tenderness 
is  partly  relieved,  and  disapiDears  entirely  after  confinement. 
Boroglyceride  or  tannic  acid  and  glycerin  are  of  use  in  some 
cases.  A  few  applications  of  nitrate  of  silver  (one  grain  to 
the  ounce)  are  helpful. 

In  case  there  is  a  free  secretion  of  the  vulvo-vaginal 
glands,  applications  of  bichloride  of  mercury — one  in  two 
thousand — should  be  tried.  In  some  obstinate  cases  I  have 
used  carbolic  acid,  one  part  in  twenty  parts  of  glycerin. 
Debilitated  and  weak- nerved  patients  require  constitutional 
treatment,  and  I  need  not  add  that  the  causes — if  any  can 
be  detected — should  be  removed.  Physiological  means  must 
also  come  in  as  a  part  of  the  treatment. 

Varicose  Veins  of  the  Vulva. — The  veins  about  the  vulva, 
like  those  in  other  portions  of  the  body,  may  become  vari- 
cose. This  commonly  occurs  in  those  who  have  borne  chil- 
dren ;  indeed,  pregnancy  appears  to  stand  in  a  causative  re- 


DISEASES  OP  THE  EXTERNAL  GENITALS.  267 

lation  thereto,  although  cases  undoubtedly  do  occur  in  those 
who  have  never  been  pregnant. 

Causation. — I  am  satisfied  that  certain  defects  in  the 
structure  of  the  veins — and  in  fact  in  the  circulatory  system 
generally — predispose  to  this  affection.  Defects  in  the  elastic 
tissue,  which  leave  the  skin  unsupported,  I  think  may  be  a 
cause. 

Anything  which  obstructs  the  nervous  circulation  will, 
by  increasing  the  intravenous  pressure,  tend  to  produce  this 
varicose  condition,  whether  it  be  a  pregnant  uterus,  a  tumor, 
or,  as  mentioned  by  Winckel,  the  straining  at  stool  in  case  of 
obstinate  constipation.  Those  who  stand  day  after  day,  such 
as  saleswomen,  or  sit  all  day,  as  typewriters  and  seamstresses 
do,  are  likely  to  suffer  from  this  affection. 

Symptomatology. — A  patient  may  have  well-marked  vari- 
cose veins  of  the  vulva  and  yet  be  entirely  unaware  of  the 
fact ;  or  a  sense  of  heat  and  irritation  may  be  experienced  of 
so  disagreeable  a  nature  as  to  cause  her  to  consult  a  physi- 
cian, when  the  presence  of  varicose  veins  may  be  recognized. 
In  still  other  cases  the  fullness  due  to  the  swelling  is  so  great 
as  to  attract  attention,  though  other  symptoms  may  be  ab- 
sent. 

Physical  Signs. — Upon  examination,  in  slight  cases,  the 
varicose  condition  of  the  veins  is  observed.  In  more  aggra- 
vated cases,  however,  there  may  be  so  much  tumefaction  of 
the  labia  and  other  parts  as  to  mask  this  peculiar  condition 
of  the  veins.  Holden  describes  a  case  in  which  a  tumor 
existed  as  large  as  the  head  of  a  child.  The  diagnosis  in 
these  cases  is  to  be  made  by  excluding  the  other  affections  by 
methods  which  are  elsewhere  described. 

Treatment. — Little  can  be  done  in  the  way  of  radical 
treatment  for  this  condition  short  of  surgical  operations ; 
but  the  physician  can  do  much  to  relieve,  and,  in  cases  seen 
early  enough,  even  entirely  cure.  The  bowels  should  be 
attended  to,  so  that  there  may  not  be  constipation  and  the 
accompanying  straining  at  stool. 

The  patient  should  rest  as  much  as  possible  in  the  reclin- 

18 


268  MEDICAL  GYNECOLOGY. 

ing  position  with  the  pelvis  elevated — in  other  words,  take 
the  postural  treatment  recommended  in  the  treatment  of  vari- 
cose veins  of  the  broad  ligaments.  Local  cold-water  bathing 
and  sea  bathing  are  very  beneficial,  and  astringent  washes,  to 
give  tone  to  the  skin  and  restore  support  to  the  veins,  are 
also  useful. 

If  the  varicosity  is  marked  and  shows  a  tendency  to 
increase,  some  relief  may  be  obtained  by  a  pad  so  applied  as 
to  give  the  veins  the  support  which  they  lack  by  reason  of 
the  weakness  of  their  walls.  It  should  be  constantly  borne  in 
mind  that  when  these  veins  assume  a  marked  varicose  con- 
dition, there  is  a  possibility  of  their  becoming  so  distended 
during  pregnancy  as  to  rupture  at  the  time  of  delivery. 

Vaginitis. — Much  that  has  been  said  regarding  vulvitis,  con- 
sidered from  the  standpoint  of  the  physician,  applies  with 
equal  pertinence  to  vaginitis.  It  must  be  conceded,  however, 
that  vaginitis,  being  often  a  secondary  affection,  requh'es  sur- 
gical care.  ]S"evertheless,  there  are  many  patients  with  vagi- 
nitis who  come  under  the  care  of  the  physician,  and  can 
be  successfully  treated  by  medical  management  alone.  The 
physician  should  be  prepared  to  make  a  diagnosis  and  to 
institute  appropriate  treatment  in  order  to  help  those  who  do 
not  or  will  not  place  themselves  under  the  care  of  a  surgeon. 
He  should  know  the  limit  of  his  ability  to  manage  the  dis- 
ease, so  that  he  may  transfer  cases  where  medical  care  is 
incompetent.  How  to  differentiate  in  this  respect  will  be 
pointed  out  hereafter. 

I  am  the  more  desirous  of  making  this  subject  plain  to  the 
general  practitioner  owing  to  the  fact  that  many  times  patients 
apply  to  their  family  physician  for  relief  from  a  vaginitis,  and, 
failing  to  get  proper  medical  care,  drift  to  other  secondary  dis- 
eases which  are  difficult  to  cure  by  surgical  treatment. 

The  vagina  is  seldom  affected  with  idiopathic  inflamma- 
tion ;  vaginitis,  therefore,  occurs  as  the  result  of  some  specific 
cause,  or  is  secondary  to  inflammation  of  some  other  organ, 
such  as  endometritis.  There  are  several  varieties  of  vaginitis. 
Classified  according  to   the  intensity  and  duration  of  the 


DISEASES  OP   THE  EXTERNAL   GENITALS.  269 

affection,  there  are  the  acute  and  chronic  forms  ;  when  classi- 
fied according  to  the  causation,  there  are  a  number  of  forms, 
the  most  important  of  which  are  gonorrhoeal,  erythematous — 
sometimes  called  erysipelatous — and  diphtheritic.  As  a  rule, 
the  inflammation  is  general,  involving  the  whole  canal ;  occa- 
sionally it  is  circumscribed,  and  then  it  is  found  just  within 
the  vulva,  or  else  at  the  upper  part. 

Pathology. — Owing  to  the  anatomical  peculiarities  of  the 
vagina,  it'  is  not  fully  susceptible  of  the  catarrhal  form  of 
inflammation  so  common  to  mucous  membranes  elsewhere. 
From  the  fact  that  the  vaginal  mucous  membrane  resembles 
in  structure  the  skin,  and  that  there  are  few  mucous  follicles 
found  in  it,  vaginitis  in  its  pathology  is  more  like  dermatitis 
than  like  the  ordinary  inflammation  of  mucous  membranes. 

Congestion,  transudation  of  serum,  premature  exfoliation 
of  the  epithelium,  and,  in  well-defined  cases,  the  formation 
of  pus,  are  the  characteristic  results  of  acute  vaginitis.  In 
the  subacute  form  there  is  less  congestion  and  less  pus  ;  oth- 
erwise the  inflammatory  lesions  are  the  same.  This  may  be 
briefly  stated  as  follows :  Vaginitis  occurs  either  as  erythema- 
tous, purulent,  or  exudative ;  never  as  purely  and  well-de- 
fined catarrhal. 

The  morbid  appearances  in  these  forms  differ.  Erythema- 
tous vaginitis  is  characterized  by  great  capillary  congestion, 
which  gives  the  intense  redness  of  the  first  stage  of  this  form 
of  inflammation.  Then,  as  the  disease  advances,  there  is  ex- 
foliation of  the  epithelium.  Sometimes  it  comes  off  in  thin 
flakes,  resembling  in  this  respect  the  exfoliation  of  the  cuticle 
in  dermatitis.  This  leaves  the  mucous  membrane  denuded  of 
its  epithelium,  and  gives  a  glazed  appearance  to  the  whole 
canal.  During  this  time  there  may  be  a  free  serous  secretion 
and  some  pus  found,  but  these  are  not  profuse  in  all  cases. 

In  purulent  vaginitis  the  lesions  are  the  same  as  already 
described.  In  the  exudative  forms  the  characteristic  lesions 
are  present — the  diphtheritic  membrane  in  diphtheria,  the 
croupous  in  that  form  of  inflammation.  There  are  other 
forms  of  vaginitis  mentioned  by  some  authors,  but  they  are 


270  MEDICAL  GYNECOLOGY. 

peculiar  in  regard  to  causation,  while  in  their  pathology  they 
do  not  differ  materially  from  those  described. 

Symptomatology.— l^^iQ  symptoms  in  the  acute  form  are 
a  sense  of  internal  heat  and  fullness.  These  increase  in  in- 
tensity, and  pain  in  the  vagina  and  uterus  comes  on.  Vesical 
and  rectal  tenesmus  are  present  in  severe  cases,  and  urination 
and  defecation  may  be  somewhat  painful.  The  urine  causes 
violent  smarting  of  the  inflamed  parts  about  the  vulva  with 
which  it  comes  in  contact.  So  severe  is  the  pain  in  some 
cases  during  and  after  urination  that  the  patient  resists  the 
inclination  until  the  power  of  evacuation  is  lost  and  there  is 
retention. 

There  are  also  constitutional  disturbances.  At  first  there 
is  slight  fever,  and,  following  that,  loss  of  appetite  and  debil- 
ity. The  discharge  is  profuse  and  sero-purulent  in  character, 
and  it  causes  excoriation  of  the  external  parts,  which  often 
extends  to  the  limbs.  If  strict  cleanliness  is  not  observed, 
the  discharge  decomj)oses  and  causes  a  very  disagreeable 
odor.  Some  one  stated  that  the  discharge  in  vaginitis  had 
an  alkaline  reaction  which  was  diagnostic,  because  the  normal 
secretion  of  the  vagina  is  acid,  and  the  change  is  evidence  of 
inflammation.  I  have  not  been  able  to  verify  the  statement. 
In  the  subacute  and  chronic  forms  of  vaginitis  the  symptoms 
are  the  same  in  character  but  less  in  degree.  In  fact,  the 
annoying  discharge  is  the  only  symptom  observed  in  many 
of  these  mild  cases. 

Physical  Signs. — By  inspection  of  the  parts  when  the 
labia  are  separated,  the  characteristic  discharge  can  be  seen 
and  recognized.  It  differs  from  that  of  vulvitis  in  being  less 
tenacious.  The  mucous  glands  about  the  vulva  give  to  the 
discharge  of  vulvitis  a  cohesiveness  which  is  not  found  in 
that  of  vaginitis.  The  use  of  a  speculum  will  show  the  in- 
flamed appearance  of  the  membrane  and  the  discharge  which 
is  present. 

The  anterior  and  lateral  portions  only  of  the  walls  of  the 
vagina  are  seen  through  the  Sims  speculum,  but  by  watch- 
ing the  folding  together  of  the  posterior  and  anterior  walls, 


DISEASES  OP  THE  EXTERNAL  GENITALS.  271 

as  the  speculum  is  withdrawn,  the  whole  canal  can  be  thor- 
oughly inspected.  It  is  seldom  that  the  physician  requires 
to  use  a  speculum. 

The  difference  between  the  signs  of  acute  and  subacute 
inflammation  is  simply  in  the  intensity  of  the  congestion,  the 
extent  of  the  canal  involved,  and  the  quantity  and  character 
of  the  discharge.  To  distinguish  gonorrhoeal  vaginitis  from 
the  nonspecific  forms  the  microscope  alone  is  sufficient. 
When  there  is  a  question  regarding  the  nature  or  the  cause, 
specimens  of  the  discharge  should  be  examined  for  the  gono- 
cocci. 

Causation. — There  is  a  predisposition  to  vaginitis  in  those 
of  delicate  health  and  strumous  diathesis,  but  it  is  not 
marked.  Judging  from  my  own  observations,  the  common 
causes  of  vaginitis  are  gonorrhoeal  virus,  vulvitis,  metritis — 
especially  puerperal — erythematous  affections,  subinvolution 
menstrualis,  and  habits  of  personal  uncleanliness,  physical 
and  moral,  the  latter  too  well  known  by  physicians  to  need 
more  than  mention. 

Subacute  and  chronic  vaginitis  may  be  caused  by  any 
inflammation  in  the  neighborhood  of  the  canal.  Dysentery, 
for  example,  not  infrequently  causes  vaginitis,  and  patho- 
genic germs  have  been  credited  with  producing  it,  but  this 
is  not  completely  verified.  When  it  occurs  in  connection 
with  the  eruptive  diseases,  the  cause  is,  of  course,  the  specific 
morbid  material  which  produces  the  constitutional  disease. 

Prognosis. — With  proper  care  vaginitis  can  be  arrested 
and  recovery  secured  without  any  permanent  lesions.  It  is 
liable  to  recur  if  caused  by  gonorrhoea.  Sometimes  perma- 
nent damage  is  done  to  the  canal  when  the  vaginitis  is  due  to 
any  of  the  eruptive  diseases  or  diphtheria. 

Treatment. — In  the  past,  treatment  of  vaginitis  has  con- 
sisted mainly  in  the  frequent  use  of  medicinal  douches.  The 
agents  used,  and  the  means  and  ways  of  using  them,  have 
varied  greatly  with  different  practitioners.  Very  recently  a 
new  method  of  treatment  has  been  brought  to  the  notice  of 
the  profession  by  Dr.   Engelmann,  of  St,  Louis.     He  terms 


272  MEDICAL  GYNECOLOGY. 

liis  method  the  dry  treatment,  which  consists  in  the  use  of 
medicinal  powders  and  medicated  tampons. 

A  number  of  years  ago  I  tried  this  method,  in  an  imperfect 
and  limited  way,  in  the  treatment  of  vaginitis  among  the  in- 
sane, and  obtained  experience  enough  to  know  that  it  is  of 
great  value.  I  find,  however,  that  while  using  certain  agents 
in  powdered  form,  and  also  the  tampon,  the  discharge  from 
the  inflammation  and  the  powder  lodge  in  the  folds  of  the 
mucous  membrane,  and  it  is  necessary  to  use  a  vaginal  douche 
occasionally  in  order  to  make  the  treatment  effective. 

In  acute  vaginitis  I  employ  what  may  be  called  a  mixed 
treatment,  using  the  medicinal  agents  and  powder  with  tam- 
pon, and  occasionally  employing  the  douche  in  the  following 
way  :  After  cleansing  the  mucous  membrane  thoroughly  with 
a  douche  of  warm  water  and  borax — a  drachm  to  the  quart — 
I  then  apply  subnitrate  of  bismuth  and  prepared  chalk,  equal 
parts,  and  introduce  a  tampon  of  borated  cotton,  the  tampon 
being  so  arranged  as  to  thoroughly  keep  the  vaginal  walls 
apart.  At  the  end  of  twelve  hours  the  tampon  is  removed, 
and  any  accumulation  of  the  discharge  and  powder  is  com- 
pletely washed  away  with  a  douche  and  the  tampon  replaced. 
At  the  end  of  the  next  twelve  hours  the  tampon  is  removed, 
the  douche  of  borax  and  water  employed,  and  the  powdering 
repeated.  The  powder  is  applied  with  a  very  useful,  ingen- 
ious applicator  made  by  McKesson  and  Robbins. 

In  acute  cases,  where  there  is  much  pain,  and  especially 
if  due  to  a  specific  cause,  I  use  iodoform  in  place  of  the 
bismuth.  If  the  trouble  does  not  yield  promptly  to  this 
treatment,  I  give  up  the  dry  dressing,  and  every  third  day 
apply  to  the  entire  canal,  by  means  of  the  atomizer  with 
strong  pressure,  a  solution  of  nitrate  of  silver,  one  grain  to 
the  ounce,  or  sulphate  of  zinc,  one  half  grain  to  the  ounce. 
I  find  that  such  mild  solutions,  applied  with  considerable 
force  with  the  atomizer,  so  as  to  diffuse  the  application  thor- 
oughly, produce  a  far  more  marked  effect  than  much  stronger 
solutions  used  as  a  douche. 

The  method  of  application  or  spraying  the  canal  is  as 


DISEASES  OP  THE  EXTERNAL  GENITALS.  273 

follows  :  A  Sims  speculum  is  introduced,  and  when  the  canal 
is  distended  by  pressure,  the  spray  is  thoroughly  applied  to 
the  upper  portion  of  the  canal  and  to  the  anterior  and  lateral 
walls,  and  the  posterior  wall  is  sprayed  as  the  speculum  is 
gradually  withdrawn.  In  the  intervening  days  between  these 
applications  I  employ  once  or  twice  a  day  a  vaginal  do  ache 
of  a  solution  of  sulphate  of  zinc,  sixty  grains  to  the  quart  of 
warm  water. 

In  cases  that  can  not  be  so  carefully  watched  and  treated 
I  rely  almost  wholly  upon  the  sulphate-of-zinc  solution,  used 
as  a  vaginal  douche,  two  or  three  times  a  day  at  first,  and 
subsequently  once  a  day.  This  answers  remarkably  well  in 
a  great  majority  of  cases,  but  there  is  a  constant  liability  to 
miss  a  portion  of  the  canal,  especially  the  upper  and  poste- 
rior fornix.  To  overcome  this,  an  application  of  the  nitrate 
of  silver  or  sulphate  of  zinc  is  to  be  made  to  these  neglected 
parts  once  or  twice  a  week  through  the  speculum. 

This  simple  treatment  is  usually  sufficient  in  all  ordinary 
cases,  but  whenever  the  disease  is  specific  in  its  origin  and 
is  complicated  with  urethritis  and  endometritis,  then  these 
affections  should  be  treated  simultaneously  in  the  ordinary 
way  by  the  surgeon.  The  general  health  should  be  looked 
after  carefully  and  any  derangement  or  defect  corrected.  I 
have  admitted  treatment  that  might  more  properly  be  given 
under  a  surgical  care  of  the  case,  but  it  is  of  such  a  minor 
order  that  most  physicians  are  competent  to  employ  it. 


CHAPTER  XXIII. 

FUNCTIONAL   DISEASES   OF   THE  NERVOUS   SYSTEM   ASSOCIATED 
WITH  DISEASES    OF   THE   SEXUAL   OEGANS. 

The  nerve  element  in  diseases  of  women  is  a  potent  fac- 
tor in  both  tlie  cause  and  the  cure  of  their  manifold  maladies. 
Living  on  their  nerves,  passions,  and  prejudices,  the  reaction 
must  be  conducive  to  nerve  misrule.  The  brain  and  spinal 
cord  lose  their  control  over  their  subordinates.  The  nervous 
wear  shows  itself  very  frequently  by  distinct  pelvic  symp- 
toms, prominent  among  which  are  a  bearing-down  feeling, 
backache,  scanty,  painful,  delayed,  or  suppressed  menstrua- 
tion, irritable  bladder,  and  ovarian  pain,  usually  on  the  left 
side.  True,  skin  affections,  neuralgia,  insomnia,  and  general 
bodily  weariness  may  accompany  these  other  marked  symp- 
toms, yet  the  patient — and  chiefly  her  friends — will  direct  all 
their  attention  toward  this  "womb  trouble." 

Oftentimes  the  physician  discovers  some  slight  malposition 
of  the  uterus  or  some  insignificant  catarrhal  lesion,  and  these 
might  be  magnified  into  certain  causes  of  a  condition,  that  a 
broader  observer  would  at  once  recognize  as  mere  waste,  or 
nerve  exhaustion.  A  headache  does  not  mean  brain  disease  ; 
then  why  should  backache  mean  uterine  disease,  or  ovarian 
neuralgia  become  a  reason  for  thinking  of  ovariotomy  ? 

The  condition  that  I  have  described — this  weariness  or 
jaded,  nervous  state — is  not  neurasthenia,  nor  is  it  necessarily 
associated  with  disease  of  the  sexual  organs  ;  but  I  have  often 
found  functional  disturbances  of  the  mind  most  difficult  to 
classify  which  were  directly  dependent  upon  diseases  of  the 
sexual  organs.     The  disturbances  under  consideration  most 

274 


FUNCTIONAL  DISEASES  OP  THE  NERVOUS  SYSTEM.        275 

frequently  appear  as  exaggerations  of  what  we  call  "  dispo- 
sition." We  speak  of  a  good  or  bad  disposition  or  "tem- 
per," meaning  thereby  the  usual  way  of  looking  at  things 
and  behaving  toward  others. 

Fii'st  among  the  functional  disturbances  associated  with 
diseases  of  the  sexual  organs  comes  a  morbid  irritability, 
showing  itself  in  continual  fault-finding  concerning  their  en- 
vironment. Whatever  is,  is  wrong.  They  are  dissatisfied, 
complain  .continually,  lose  their  mental  equilibrium  on  the 
slightest  provocation,  and  become  known  as  exceedingly  ill- 
natured.  Young  girls  who  are  "spoiled"  are  particularly 
liable  to  attain  this  condition,  which  shows  itself  on  the 
slightest  indisposition  or  moment  of  ill-health.  But  we  may 
see  all  this  in  older  subjects  and  in  some  unmarried  ladies  of 
uncertain  age  who  exhibit  this  ill-temper,  especially  if  they 
have  been  disappointed. 

Married,  sterile  women  are  also  subject  to  this  form  of 
disturbance ;  they  are  apt  to  be  imperious  and  dictatorial. 
It  is  difiicult  to  tell  whether  this  is  the  natural  disposition,  or 
whether  it  is  an  acquired  state  due  to  morbid  mental  irrita- 
bility. The  diagnosis  is,  of  course,  easily  made  in  case  the 
physician  has  known  the  patient  before  this  mental  irritability 
manifested  itself. 

Another  form  of  disturbed  mental  function  of  an  entirely 
opposite  character  is  mental  depression,  not  anything  like  a 
true  hypochondria,  but  rather  a  lack  of  confidence,  with  dis- 
position to  be  hypercritical.  While  one  is  ajDt  to  be  quarrel- 
some and  fault-finding  toward  the  attending  physician,  an- 
other is  apologetic  and  traces  all  her  misfortunes  to  herself, 
and  is  emotional  in  a  quiet  way  without  being  able  to  give 
the  slightest  reason  for  the  tears  that  come  without  any  ap- 
parent exciting  cause. 

These  merely  hint  at  an  outline  of  the  two  directly  oppo- 
site conditions  of  mentality — temper  or  disposition.  Between 
them  all  varieties  are  to  be  found,  and  the  reason  why  they 
should  be  referred  to  here  is  that  the  gynecologist  of  neces- 
sity is  obliged  to  note  such  things  in  the  general  management 


276  MEDICAL  GYNECOLOGY. 

of  cases  under  observation.  They  are  of  most  interest  from 
the  standpoint  of  the  therapeutist,  for  the  physician  must 
take  into  account  the  peculiarities  of  disposition  of  each 
case  in  order  that  he  may  secure  the  full  confidence  of,  and 
do  the  most  toward  restoring,  each  individual  to  health  v^^ho 
may  come  under  his  care. 

The  treatment,  of  course,  must  be  psychological — that  is 
to  say,  the  medical  attendant's  tact  and  ability  to  control 
patients  and  compel  them  to  submit  to  his  will  and  wishes 
are  the  chief  therapeutic  agents.  To  control  and  direct  such 
patients  mentally  is  the  means  through  which  benefit  can 
be  secured.  Perhaps  it  might  be  well  to  classify  these 
agencies  under  the  head  of  hypnotism,  and  indeed  this  con- 
trol of  the  minds  of  patients  by  the  medical  attendant  is 
allied  to  it,  in  my  opinion.  Some  are  greatly  gifted  with  the 
power  of  securing  the  confidence  of  patients  and  controlling 
them  mentally,  and  certainly  it  is  a  power  that  should  be 
studied  as  thoroughly  as  the  tangible  remedies  of  materia 
medica. 

The  irritable  or  ill-natured  should  be  mildly  and  gently 
but  effectively  repressed,  while  the  timid  and  depressed  re- 
quire to  be  cheered  and  sustained.  This  management  of  pa- 
tients is  often  called  tact,  which  simply  means  knowing  how 
to  control  the  mind  as  well  as  the  body  in  the  use  of  thera- 
peutics. Too  often  the  doctor  of  medicine  leaves  this  to 
friends,  attendants,  or  to  the  spiritual  adviser,  but  I  have 
seldom  found  such  care-takers  well  qualified  ;  friends  usu- 
ally aggravate  rather  than  relieve.  The  doctors  of  divinity, 
too,  are  sometimes  lacking  in  tact,  and  exercise  poor  judg- 
ment, cheering  and  encouraging  those  who  should  be  con- 
demned and  chastened,  while  dwelling  upon  the  sorrows, 
sins,  and  iniquities  of  those  who  are  timid,  innocent,  and  re- 
quire to  be  freed  from  their  apprehensions  of  wrongdoing. 

This  field  of  "suggestive  therapeutics" — hypnotism,  in- 
fluence, call  it  what  you  will — is  not  only  unexplored,  but  it 
is  a  domain  that  the  conservative  are  prone  to  look  askance 
at,  for  fear  "spiritualist"  or  "mesmerist"  may  be  lightly  at- 


FUNCTIONAL  DISEASES  OP  THE  NERVOUS  SYSTEM.         277 

taclied  to  their  titles.  The  fear  is  all  too  well  grounded  ;  the 
ignorant — i.  e.,  most  people — class  all  this  moral  part  of  thera- 
peutics together  under  the  head  of  fraud. 

But  suggestive  therapeutics,  although  2i  fin-de-siecle  prod- 
uct, is  here  to  stay,  to  grow.  It  has  fallen  into  the  hands  of 
some  cunning,  smart,  bad  men  thus  far ;  but  when  the  medi- 
cal profession  shall  calmly  and  without  prejudice  study  it 
experimentally,  practically,  its  results  in  some  cases — for  it 
is  a  mistake  to  imagine  suggestion  can  be  equally  strong  to 
all — will  be  beyond  all  that  is  even  now  claimed  for  this 
"cure."  The  great  Charcot  probably  first  gave  this  school 
its  impetus,  and  to  the  French  we  owe  much  of  the  advance 
and  investigation  in  this  line  of  new  work. 

Nervous  Oppression. — Nervous  oppression  is  a  condition  of 
the  nervous  system  in  which  there  is  an  apparent,  but  by  no 
means  real,  asthenia  or  exhaustion.  It  is  as  if  the  nervous 
system  acted  under  unfavorable  conditions  of  nutrition,  and 
hence  became  functionally  perverted  to  a  marked  degree. 
This  affection  is  very  common — nearly  as  common  as  neuras- 
thenia or  nervous  exhaustion  ;  but  I  am  confident  that  it  is 
not  at  all  understood,  in  fact  is  frequently  mistaken  for  a 
neurasthenia  or  nervous  exhaustion — an  entirely  different 
condition. 

Here  is  the  proper  place  to  discuss  this  subject,  so  that  it 
may  not  afterwards  be  confounded  with  neurasthenia,  an 
affection  bearing  a  striking  resemblance  to  it,  but  one  in 
many  ways  different.  The  one  is  a  purely  functional  de- 
rangement, while  in  neurasthenia  there  is  a  continuous  ab- 
normal alteration  of  circulation. 

I  have  often  seen  patients  treated  for  nervous  exhaustion 
and  made  very  much  worse  by  this  treatment  when  they 
were  simply  suffering  from  nervous  oppression.  While  this 
condition  is  uncomplicated,  there  is  no  anaemia  or  malnutri- 
tion to  account  for  the  nervous  debility.  The  nutrient 
supply  to  the  nervous  system  seems  to  be  ample — in  fact,  in 
some  cases  excessive — many  patients  becoming  plethoric 
and  fleshy. 


278  MEDICAL  GYNECOLOGY. 

This  is  really  an  acute  condition  tending  toward  recovery 
with  proper  treatment,  or  at  times  merging  into  neurasthenia, 
although  it  is  by  no  means  to  be  regarded  as  a  first  stage  of 
neurasthenia.  Imperfect  disintegration  and  elimination  give 
rise  to  imperfect  nerve  nutrition,  should  the  condition  persist ; 
hence  one  often  sees  this  transformation  of  diseases. 

Symptoms. — The  most  prominent  symptom  is  general 
weakness,  clearly  traceable  to  the  nervous  system.  The 
patient  is  easily  fatigued  by  mental  or  physical  exertion, 
and  there  is  decided  torpor  of  mind.  An  effort  to  do  any- 
thing in  the  way  of  mental  labor  is  extremely  irksome,  diffi- 
cult, and  a  great  trial  for  the  patient,  and  one  that  is  not 
usually  attended  with  success.  Any  strong  impression  or 
shock  to  the  nervous  system  is  liable  to  produce  a  faintness, 
sometimes  actual  fainting,  with  this  peculiarity :  that  the 
patient  faints  with  a  flushed  face  and  seldom  entirely  loses 
consciousness ;  it  is  more  a  slight  bewilderment  and  simu- 
lates syncope.  Headache  is  often  present,  and  the  patients 
usually  wake  with  it  in  the  morning,  the  pain  not  being 
acute  or  neuralgic,  but  more  akin  to  that  of  deranged  cir- 
culation either  from  hypersemia  of  the  brain  or  from  some 
semitoxic  condition  of  the  blood  itself. 

These  patients  are  often  good  sleepers,  although  frequent- 
ly disturbed  by  dreams  like  anaemic  patients,  with  this  dif- 
ference :  that  the  dreams  are  more  like  nightmares.  They 
are  apt  also  to  have  pain  in  the  back  of  the  neck  with  back- 
ache. On  taking  muscular  exercise  they  become  very  easily 
fatigued  and  short  of  breath.  This  want  of  muscular  strength 
and  short  breathing  are  clearly  due  to  nervous  depression 
because  the  muscular  system  is  not  at  all  deficient.  They 
usually  have  flesh  enough,  although  it  may  be  somewhat  soft 
for  want  of  exercise.  The  appetite  is  generally  good  ;  not 
infrequently  there  is  constipation  ;  the  complexion  is  some- 
what dusky  ;  the  tongue  is  coated,  but  not  always  ;  the  urine 
is  generally  high-colored  or  muddy  ;  menstruation  is  fre- 
quently deranged,  being  delayed  or  scanty  or  both  ;  and 
there  may  be  some  leucorrhcea  even  in  those  who  are  other- 


FUNCTIONAL  DISEASES  OP  THE  NERVOUS  SYSTEM.         279 

wise  free  from  uterine  disease.  In  a  word,  there  is  a  con- 
dition that  is  best  expressed  as  excrementitious  plethora. 
Ultimate  nutrition,  disintegration,  and  elimination  are  all 
abnormal.  This  condition  is  allied  to  lith{emia,  and,  from 
the  description  of  lithsemia  and  the  uric-acid  diathesis  usu- 
ally found  in  books,  I  am  inclined  to  think  that  they  are  very 
much  of  the  same  order.  I  prefer  the  term  excrementitious 
plethora,  as  indicating  the  condition  I  have  Just  described. 

Causation. — The  most  potent  cause  is  inactivity  of  body 
and  mind,  with  general  good  living.  Sometimes  this  over- 
feeding and  inactivity  result  from  the  social  position  and 
tendency  to  indolence ;  quite  frequently,  however,  the  idle- 
ness is  enforced  because  of  some  uterine  disease,  inflamma- 
tory or  in  the  form  of  a  displacement  which  causes  suffer- 
ing should  the  patient  take  sufficient  exercise.  Some  of  the 
most  distinctive  cases  that  I  have  seen  arose  from  suddenly 
induced  amenorrhoea,  and  suspension  from  sexual  indulgence 
leads  to  the  same  state  of  affairs.  Alienists  have  observed 
that  young  widows  are  predisposed  to  insanity,  and  I  believe 
it  to  be  in  great  measure  due  to  nervous  oppression  following 
sudden  cessation  of  sexual  indulgence.  I  might  say,  then, 
in  brief,  that  inactivity,  voluntary  or  compulsory,  with  gen- 
eral nutrition  good,  are  conditions  tending  to  produce  this 
ailment.  There  is,  no  doubt,  in  many  a  predisposition  to 
this  state  arising  from  natural  peculiarities  of  organization, 
such  as  in  those  who  have  good  primary  digestion  and  as- 
similation but  a  sluggish  disintegration  and  elimination. 

Treatment. — I  was  first  led  to  consider  this  affection  a 
nervous  oppression  pure  and  simple  from  the  fact  that  the 
nervous  debility,  or  brain  and  nerve  torpor  and  apparent  de- 
bility, entirely  disappeared  under  extraordinary  exertion.  I 
have  often  seen  patients  who  have  long  been  known  as  weak 
and  inefficient  in  every  respect,  become  strong  when  some  ex- 
treme responsibility  was  thrown  upon  them,  such  as  sickness 
or  poverty,  which  compelled  extraordinary  exertion.  They 
really  lost  their  aches  and  pains  in  consequence  of  what  was 
to  them  decided  overwork.    This  same  thing  has  been  noticed 


280  MEDICAL  GYXECOLOGY. 

when  some  pleasurable  excitement  occurred.  A  young  lady, 
weak  and  debilitated,  becoming  interested  in  one  of  the  op- 
posite sex,  gradually  overcomes  her  weakness  and  does  most 
wonderful  things,  for  her,  in  the  way  of  mental  and  physical 
exertion. 

These  observations  not  only  lead  to  a  clear  conception  of 
the  pathology  or  nature  of  this  affection,  but  also  suggest  in 
part  the  line  of  treatment — namely,  well-regulated  or  system- 
atic mental  and  physical  exercise,  gradually  increased  in  se- 
verity. We  must  secure  occupations  equally  divided  between 
body  and  mind,  at  first  of  the  lightest  character,  and  gradu- 
ally increased,  especially  exercise  in  the  open  air,  and  a  rea- 
sonable amount  of  plain,  wholesome  food,  rather  less  than 
exceeding  the  patient's  demands.  In  addition  to  this,  induce 
free  elimination  from  the  bowels  and  kidneys.  I  have  found 
the  most  difficulty  in  getting  the  kidneys  to  do  their  duty  in 
those  cases,  but,  as  soon  as  I  have  succeeded,  improvement 
has  been  great.  Free  catharsis  at  the  commencement,  follow- 
ing mild  doses  of  mercury,  will  generally  start  the  bowels, 
and  kidneys  also,  and  then  the  mineral  diuretics  and  stimu- 
lating laxatives  will  keep  up  the  normal  action.  Such  cases 
very  often  do  remarkably  well ;  in  fact,  they  are  the  patients 
that,  in  my  opinion,  profit  the  most  by  the  use  of  waters  at 
the  resorts  such  as  Saratoga  and  Carlsbad. 

I  am  here  prompted  to  add  what  things  should  not  be 
taken  in  this  class  of  cases,  because  I  have  so  often  seen  great 
harm  done,  and  the  affection  continued  indefinitely,  by  mis- 
taken diagnosis,  and  consequent  improper  treatment.  I  have 
again  and  again  seen  patients,  who  complained  of  weakness 
which  could  not  be  accounted  for  by  anything  but  nervous 
debility,  submit  to  Weir  Mitchell's  rest  cure  and  forced  feed- 
ing, and  I  know  of  nothing  worse  that  could  be  done  in 
such  cases,  as  results  invariably  have  shown.  Many  of  them 
crave  stimulants  because  they  give  marked  momentary  relief, 
but  they  are  in  all  cases  made  much  worse  by  them  ;  the 
same  is  true  of  tonics.  The  rest  cure,  while  a  very  impor- 
tant therapeutic  agency  in  certain  cases,  as  will  be  seen  by 


FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM.        281 

and  by,  is  most  pernicious  in  cases  of  nervous  oppression. 
Instead  of  the  rest  cure  then,  I  would  recommend  the  "  occu- 
pation "  or  "exercise"  cure,  meaning  by  this  not  passive  ex- 
ercise, such  as  is  obtained  by  massage,  or  the  Swedish-move- 
ment cure,  but  actual  exercise,  mental  and  physical,  by  the 
patient  herself. 

Introspection. — The  term  introspection  is  here  used  to  indi- 
cate the  habit  of  thinking  about  one's  body  and  its  functions. 
It  is  a  critical  and  almost  continuous  investigation  carried  on 
by  the  mind  regarding  the  body.  Considerable  thinking 
about  self  is  necessary  in  order  to  supply  the  bodily  wants ; 
but  that  does  not  require  one  to  think  of  the  body  and  the 
functions  which  it  performs.  The  human  mind  is  largely  oc- 
cupied in  securing  the  everyday  wants  of  life.  The  large 
majority  of  the  higher  intellectual  faculties  are  exercised  in 
bringing  one  into  harmonious  relations  with  the  world  around 
in  order  to  maintain  life  and  partake  of  the  higher  mental 
enjoyments,  as  well  as  of  daily  bread.  To  think  and  labor 
diligently  to  live  and  enjoy  life,  is  the  normal  exercise  of  the 
mental  faculties.  But  when  the  wants  are  supjDlied,  food 
will  be  digested  and  assimilated  without  any  thought  or  care. 
The  heart  will  continue  its  pulsations  without  being  watched, 
and  the  lungs  will  keep  up  respiration  without  a  thought 
being  given  as  to  how  they  are  breathing. 

To  divert  the  attention  to  the  organic  functions  is  really  a 
perversion  of  mind  function,  and  while  it  is  a  useless  exercise 
of  thought,  it  also  influences  the  organic  functions  in  a  mor- 
bid way.  To  this  abnormal  affection  of  the  mind  I  have  ap- 
plied the  term  introspection.  The  natural  history  of  intro- 
spection is  usually  as  follows:  The  patient  first  discovers,  or 
is  taught,  that  certain  organs  and  tissues  of  the  body  exist, 
and  that  they  have  very  important  functions  to  perform 
(Mental  Education  of  Girls).  The  attention  is  directed  to 
these  organic  functions  and  the  duties  they  perform,  and  the 
subject  becomes  an  interesting  study  to  the  idle  and  half- 
educated,  and  is  naturally  kept  up.  It  will  soon  be  discov- 
ered that  there  are  certain  sensations  or  symptoms  developed 


282  MEDICAL  GYNECOLOGY. 

by  tlie  action  of  certain  organs,  and  if  closely  watched  these 
sensations  will  be,  at  times,  disagreeable.  This  attracts  fur- 
ther attention  and  gives  additional  interest,  and  so  the  prac- 
tice is  continued  with  increasing  industry. 

The  result  is  that  the  organic  functions  soon  become  de- 
ranged, first  from  the  disturbing  influence  of  the  mind,  and 
then  from  the  depression  which  comes  from  unnatural  occu- 
pation. There  are  few  hearts  that  will  beat  regularly  if  they 
are  watched  continually.  It  may  be  that  a  little  irregularity 
of  the  heart  action  is  common  to  every  one ;  or  it  may  be  that 
if  the  attention  be  concentrated  upon  the  heart,  its  action  will 
become  deranged  through,  per  verted  nerve  action.  Certain  it 
is  that  those  who  keep  a  systematic  watch  over  the  action  of 
their  own  hearts  are  sure  to  report  frequent  irregularities  on 
the  part  of  that  organ.  It  is  the  same  with  the  stomach. 
That  useful  and  patient  organ  will  overcome  many  trials  of 
life  if  left  to  itself  and  not  too  carefully  looked  after.  In  a 
more  marked  degree  still  will  the  sexual  organs  become  per- 
verted if  the  mind  is  permitted  to  dwell  upon  them.  When 
once  this  deranged  function  of  any  of  the  important  organs  of 
nutrition  and  reproduction  has  begun  it  is  likely  to  increase 
until  a  fixed  and  continuous  morbid  condition  is  produced, 
and  it  is  more  than  possible  that  long-continued  derangement 
of  function  may  lead  to  organic  disease.  Beyond  doubt  the 
presence  of  a  functional  disorder  predisposes  to  organic  dis- 
ease which  will  become  developed  under  exciting  causes  and 
would  not  be  operative  in  one  of  sound  health. 

Causation. — The  causes  which  produce  introspection  are 
to  be  found  in  the  overdevelopment  or  supersensitiveness 
which  may  be  inherited  or  acquired,  perhaps  both.  In  this 
age  there  is  a  marked  tendency  to  the  development  of  the 
brain  and  nervous  system,  not  so  much  in  the  way  of  in- 
crease in  quality,  as  in  their  higher  tension,  sensitiveness,  or 
excitability.  A  nervous  system  which  is  highly  sensitive  re- 
sponds to  every  impression  promptly  and  emphatically. 
Every  pain  is  acute,  every  discomfort  is  keenly  felt,  and 
hence  the  attention  of  the  mind  is  frequently  called  to  the 


FUNCTIONAL  DISEASES  OP  THE  NERVOUS  SYSTEM.        283 

wants  of  the  body.  These  conditions  are  no  doubt  the  great 
factors  in  predisposing  to  introspection,  so  far  as  the  mental 
and  physical  conditions  of  men  and  women  are  concerned  at 
the  present  day.  Perhaps  these  conditions  are  more  preva- 
lent in  this  country  than  elsewhere.  People  who  have  been 
poor  quite  frequently  become  rich,  and,  while  freed  from  the 
necessity  of  making  great  efforts  to  live,  they  have  not  by 
education  and  habit  acquired  the  faculty  of  continuous  nor- 
mal occuxDation.  Many  such  have  but  little  interest  in  public 
matters,  and  not  sufficient  regard  for  art,  science,  or  literature 
to  occupy  their  time  ;  hence  they  naturally  turn  to  social 
pleasures,  which,  though  to  a  certain  extent  wholesome,  are 
demoralizing  if  one's  whole  life  is  given  to  them.  In  this  re- 
gard the  poor  are  often  better  off  than  the  rich.  The  con- 
stant occupation  of  the  poor,  which  raises  the  mind  above  the 
petty  discomforts  of  life,  contributes  largely  to  maintain  the 
harmony  of  action  between  the  nervous  and  the  nutritive 
systems. 

Certain  errors  in  the  methods  or  principles  of  home  and 
school  education,  already  referred  to,  are  peculiarly  baneful 
in  their  results. 

Treatment. — The  great  object  should  be  to  guard  against 
the  establishment  of  the  habit  of  introspection.  This  pre- 
vention is  in  this  connection,  as  it  always  is,  far  more  impor- 
tant than  cure.  The  surest  way  to  prevent  is  to  carefully 
study  the  causes  of  this  trouble,  outlined  above,  and  then  to 
carefully  guard  against  them.  In  a  word,  it  may  be  stated 
that  the  mind  should  be  continually  occupied  with  interest- 
ing subjects  outside  of  self.  Never  should  the  child  or  girl 
be  allowed  to  make  her  own  body  the  subject  of  study. 
There  are  things  that  some  people  should  not  know. 

When  introspection  has  been  cultivated  until  it  has  be- 
come a  fixed  habit  or  affection,  the  most  careful  and  pro- 
longed treatment  is  necessary  to  eradicate  it.  Indeed,  it  is 
often  incurable,  especially  if  the  subject  is  past  the  age  of 
twenty  or  twenty-five.  I  have  occasionally  seen  recovery 
take  place  in  well-marked  cases  by  a  change  from  the  par- 

19 


284  MEDICAL   GYNECOLOGY. 

ental  home  to  the  cares  and  duties  of  married  life.  A  girl 
thoroughly  spoiled  by  her  parents,  until  she  thinks  of  little 
else  but  herself,  may  become  interested  in  some  one  else. 
Once  happily  married,  she  may  have  new  interests  and  duties 
thrust  upon  her  which  may  teach  her  to  forget  self  in  her  de- 
votion to  others.  If  this  is  not  the  case,  then  the  physician 
may  give  relief  by  instituting  a  systematic  course  of  treat- 
ment which  has  constant  occupation  for  its  basis.  Traveling 
with  a  competent  companion  or  in  a  party  with  wholesome 
minds  will  often  do  well.  If  that  is  not  practicable,  system- 
atic exercise,  mental  and  physical,  with  recreations,  amuse- 
ments, bathing,  and  careful  diet,  all  so  arranged  as  to  occupy 
the  time,  is  the  general  method  of  management  to  be  recom- 
mended. 

This  subject  is  closely  related  to  "The  Invalid  Habit," 
and  the  chapter  on  that  topic  may  be  referred  to  for  further 
facts  regarding  the  treatment  of  introspection. 


CHAPTER  XXiy. 

HYSTEEIA, 

The  term  hysteria  is  applied  to  an  extraordinary  variety 
of  functional  disturbances  of  the  cerebro-spinal  and  sympa- 
thetic nervous  systems.  These  derangements  of  nerve  func- 
tions arise  primarily  from  defective  and  inharmonious  devel- 
opment and  imperfect  training.  The  deranged  functional 
action  of  the  nervous  system  develops  functional  disorders 
of  the  nutritive  and  motor  systems,  in  almost  endless  variety 
and  character. 

In  order  to  comprehend  the  nature  of  hysterical  affections 
and  their  diverse  manifestations,  it  is  necessary  to  understand 
the  peculiarities  of  the  character  of  the  organization,  which  I 
call  the  hysterical  personality  or  constitution.  This  implies  a 
peculiar  kind  of  type  or  character  of  brain  and  nervous  sys- 
tem, which  differs  from  the  neurotic,  the  epileptic,  and  the 
criminal  brain. 

Without  knowing  much  of  the  characteristic  anatomy  of 
the  brain  and  nervous  system  of  the  hysterical  subject,  there 
are  certain  manifestations  which  can  be  comprehended. 
There  is,  first,  defective  will  power,  so  constantly  present  that 
it  indicates  an  imperfect  development  in  that  portion  of  the 
brain  which  supplies  will  power  and  cerebral  co-ordination. 
There  is,  relatively,  a  high  development  of  the  emotional 
brain  element,  and  I  presume  that,  in  consequence  of  these 
conditions,  there  is  an  extreme  susceptibility  to  external  im- 
pressions. Whatever  the  cause  may  be,  there  is  this  inability 
on  the  part  of  the  hysterical  personality  to  adapt  herself  to 
the  environments.     In  referring  to  the  characteristics  of  sex 

285 


286  MEDICAL  GYNECOLOGY. 

given  in  the  beginning  of  this  %york,  it  will  be  found  that 
women  naturally  have  the  peculiarities  of  organization  which 
predispose  to  hysterical  outbreaks,  and  this  is  confirmed  by 
the  fact  that  hysteria  is  peculiar  to  women.  The  fact  that 
it  has  occasionally  been  found  in  male  subjects  should  not 
count,  because  it  only  occurs  in  those  who  are  of  feminine 
constitution. 

Pathology. — Hysteria  has  no  morbid  anatomy  ;  at  least 
none  has  been  discovered.  Still,  the  pathology  of  hysteria  is 
undoubtedly  defective  structure.  Lesions  of  quantity  and 
quality  in  parts,  and  normal  quantity  and  quality  in  others, 
produce  imperfect  harmony  and  want  of  balance  in  structure, 
which  are  causes  of  irregular,  imperfect  function.  Medical 
science  may  not  be  able  to  jDoint  to  this  or  that  form  and 
character  of  brain  and  nervous  system  and  say,  "  This  is  hys- 
terical and  that  is  not  "  ;  but,  by  observing  the  general  organ- 
ization and  noting  carefully  its  manifestations  in  disposition 
and  character,  the  hysterical  personality  can  be  detected. 

The  terms  hysteria  and  hystero-epilepsy  imply  that 
woman  is  subject  to  those  affections  owing  to  her  sexual 
organs.  Such  is  not  the  case.  Her  whole  organization  is 
responsible,  and  if  any  part  is  more  so  than  another  it  is  the 
peculiar  characteristics  of  her  brain  and  nervous  system, 
which  predispose  to  hysteria,  and  her  sexual  organs,  which 
may  act  as  exciting  causes  and  indirectly.  This  will  be 
brought  out  when  the  causation  is  discussed. 

Clinical  History. — The  character  of  the  brain  organiza- 
tion and  mental  constitution  of  those  who  are  hysterical  has 
been  pointed  out,  and  the  practitioner  has  little  that  is  defi- 
nite to  guide  him,  in  the  way  of  physical  signs,  to  a  diag- 
nosis. There  are  so  many  forms  of  hysteria  that  differ  so 
widely  that  one  can  hardly  understand  that  the  extreme 
types  or  forms  can  be  the  same  disease. 

The  manifestations  of  the  brain  functions  or  symptoms, 
objective  and  subjective,  are  the  only  guides  by  which  the 
nature  of  the  cases  can  be  obtained.  First  of  all,  it  is  neces- 
sary to  determine  if  there  is  a  hysterical  tendency  because 


HYSTERIA.  287 

of  the  nature  of  the  organization  of  the  brain  and  nervous 
system.  While  this  is  the  most  essential  to  the  diagnosis,  it 
is  the  most  difficult  to  get  at,  owing,  perhaps,  to  the  fact  that 
the  subject  has  not  received  sufficient  attention.  Tempera- 
ment does  not  aid  much,  though  temperament  as  the  term  is 
used  can  be  readily  determined.  It  might  be  presumed,  or 
supposed,  that  those  of  the  nervous  temperament  would  be 
the  most  hysterical,  but  clinically  it  is  found  not  to  be  so. 
That  which  has  been  called  by  the  neurologist  the  neurotic 
temperament  does  not  apply  to  the  hysterical  subject.  It  is 
a  fact,  also,  that  those  of  the  phlegmatic  temperament  or 
apatMques  may  have  hysteria,  and  often  do.  The  symptoms 
which  have  been  of  most  value  in  my  investigations  are  sensi- 
tiveness and  apprehension  of  anything  which  might  injure 
self,  without  overmuch  sympathy  with  others ;  marked  pre- 
dominance of  the  emotions,  and  want  of  will  power,  insta- 
bility ;  and  a  generally  explosive  conversation,  the  patient 
dealing  in  exclamations  on  all  occasions. 

Classihcation  is  difficult  and  imperfect.  The  terms  typ- 
ical, mild,  severe,  and  complicated,  which  are  designations  of 
the  form  or  variety  of  diseases  which  are  met  with  in  general, 
do  not  apply  to  hysteria,  because  it  includes  excellent  imita- 
tions of  a  great  number  of  diseases.  In  the  practice  of  gyne- 
cology I  have  noticed  certain  classes  or  groups  which  pre- 
dominate, and  these  I  may  mention  here.  The  mildest  and 
perhaps  the  most  frequent  form  is  that  of  slight  exaggerations, 
a  peculiarity  of  the  characteristics  of  the  brain  functions  of 
given  cases.  The  patient  is  morbidly  sensitive— that  is,  she 
is  predisposed  to  hysteria.  Deep  sorrow,  great  joy,  and  pro- 
found apprehensions  are  awakened  by  insufficient  causes. 
Tears  and  laughter  come  in  quick  succession,  and  are  so  ex- 
tremely pronounced  that  patients  are  said  to  laugh  and  cry  hys- 
terically. Exaggerated  emotions  and  irritability  of  temper, 
with  agreeable  happy  moods  that  come  and  go,  express  the  his- 
tory fairly  well.  All  symptoms,  in  general,  come  and  go — i.  e., 
they  are  intermittent,  not  persistent,  and  they  have  "fits  "  of 
ill  feeling  and  queer  action.     If  there  is  anything  constant  in 


288  MEDICAL  GYNECOLOGY. 

the  history  of  hysteria  it  is  irregularity,  changeableness,  and 
want  of  periodicity.  The  history  and  symptoms  seldom  re- 
main long  the  same,  nor  do  the  attacks  recur  in  precisely  the 
same  form,  especially  in  the  class  now  being  considered — the 
mild  mental  derangements  of  function.  This  form  of  hysteria 
is  nothing  more  than  an  exaggerated  functional  action,  which 
is  normal  to  the  subject  of  a  certain  kind  of  brain  and  nerves 
under  certain  conditions  of  life — surroundings  that  would  or 
might  be  favorable  to  health  and  functional  activity  in  those 
of  a  more  perfect  or  better-balanced  mental  organization. 

The  evidence  of  mental  perversion  has  been  referred  to  in 
discussing  the  peculiar  characteristics  of  hysterically  dis- 
posed subjects.  There  is  exaggeration  of  the  normal  emo- 
tions. Joy  and  sorrow,  expressed  in  crying  and  laughing, 
are  induced  by  slight  causes,  and  are  often  uncontrollable  ; 
they  pass  off,  to  recur  on  slight  provocation.  Fits  of  depres- 
sion and  listlessness  come  and  go :  morbid  irritability  and 
capriciousness  of  temper  always  exist.  The  moral  sense  is 
often  perverted.  The  disposition  to  magnify  one's  ills  is 
often  carried  to  falsification.  Whimsical  nothings  are  in- 
vented to  attract  attention  and  service  to  the  troubles  of  the 
patient.  Such  patients  violently  hate  those  who  venture  to 
disbelieve  their  stories,  and,  on  the  other  hand,  they  are 
extremely  devoted  to  those  who  will  sympathize  with  them 
and  listen  to  their  tales  of  woe.  The  disposition  to  deceive  is 
often  manifested,  and  they  will  do  all  sorts  of  foolish  and 
cruel  things  to  themselves  in  order  to  excite  sympathy. 

In  those  cases  of  active  hysteria  caused  by  disease,  or  more 
particularly  functional  derangement  of  the  sexual  organs,  cer- 
tain symptoms  are  present  that  are  to  some  extent  diagnostic. 
Such  patients  are  disposed  to  refer  their  pains,  aches,  and 
irritations  to  the  sexual  organs.  Those  of  the  sthenic  or 
catabolic  variety,  in  whom  the  sexual  impulse  or  appetence 
is  strong  but  unexercised,  are  at  times  vivacious,  subject  to 
fits  of  laughter,  and  aggressive  in  company,  and  they  have 
fits  of  anger  on  slight  provocation,  while  the  asthenic  or 
anabolic  are  weak,  languid,    despondent,  and  complain  of 


HYSTERIA.  289 

weakness  of  the  sexual  organs.  They,  if  thoroughly  confid- 
ing, admit  that  they  have  "  dreams  that  are  not  all  dreams," 
and  from  which  they  awaken  greatly  exhausted.  They  re- 
cover and  become  more  cheerful,  only  to  relapse. 

The  sthenic  have  sometimes,  and  to  a  marked  degree, 
periodical  convulsions  of  an  active  or  violent  type,  and  in  the 
asthenic  convulsions  are  less  active,  resembling  rather  faint- 
ings.  The  peculiarity  of  the  hysterical  fainting  is  that  there 
is  generator  circumscribed  flushing  of  the  face,  and  the  pulse 
is  not  so  feeble  as  in  cardiac  syncope.  These  paroxysms  come 
more  frequently  at  the  menstrual  period.  There  is  often 
dysmenorrhoea  that  is  purely  hysterical  and  is  characterized 
by  irregularity.  Sometimes  they  appear  to  suffer  violently, 
and  at  other  times  or  periods  they  do  not  suffer  at  all.  Ex- 
cessive secretion  of  the  vulvo-vaginal  glands  precedes  and 
accompanies  these  hysterical  explosions.  All  the  symptoms 
of  the  ordinary  forms  of  uterine  and  ovarian  disease  are 
simulated  and  greatly  exaggerated. 

In  the  more  marked  cases  of  hysteria,  in  addition  to  the 
perverted  brain  function,  there  is  a  great  variety  of  functional 
derangements  of  all  the  organs  of  the  body,  such  as  disorders 
of  motion,  showing  itself  in  paresis  of  the  extremities,  most 
frequently  of  the  lower  ones,  the  patient  declaring  that  she  is 
unable  to  walk  or  move.  Of  this  all  degrees  are  noticed, 
from  almost  complete  paralysis,  which  is  very  rare,  to  slight- 
ly diminished  motion.  In  this  hysterical  paresis  or  paralysis 
the  muscles  respond  to  the  electric  current,  and  show  no 
diminution  in  their  excitability.  Sensibility  in  those  cases  is 
sometimes  diminished.  Another  peculiarity  in  these  forms  is 
the  rapid  improvement  which  sometimes  takes  place,  to  be 
followed  by  relapse,  which  comes  as  suddenly.  The  paralysis 
is  almost  always  increased  by  any  excitement,  especially  of  an 
emotional  character.  Occasionally,  too,  it  shifts  its  location  : 
first,  in  one  arm  or  limb  there  is  a  diminution  of  motor  power, 
and  then  it  changes  to  the  other  side.  The  upper  extremities 
are  less  often  affected  than  the  lower.  Paralysis  of  the  laryn- 
geal muscles  is  quite  common,  giving  rise  to  a  hysterical 


290  MEDICAL  GYNECOLOGY. 

aphonia,  the  peculiarity  of  which  is  that  the  patient  appears 
to  be  nnable  to  make  an  effort  to  speak,  and  so  the  whisper 
is  soft,  almost  inaudible,  and  it  differs  in  this  respect  from 
the  hoarse  or  rough  whisper  of  those  whose  vocal  cords  are 
damaged  from  syphilis  or  tuberculosis.  This  aphonia,  too, 
comes  suddenly  and  disappears  as  suddenly,  to  occur  again. 

Continuous  or  permanent  contraction  and  rigidity  of  mus- 
cles occur  frequently  in  hysterical  subjects,  and  may  follow 
the  hysterical  paralysis  or  happen  independently  of  it.  Some- 
times this  rigidity  affects  one  whole  side  of  the  body,  and 
again  the  legs  are  rigid  and  occasionally  distorted,  imitating 
all  sorts  of  deformities,  such  as  club  foot  and  the  like.  Con- 
traction of  single  Joints  often  occurs  and  is  very  persistent, 
the  knee  seeming  to  be  the  favorite  joint  for  these  hysterical 
manifestations.  Disorders  of  sensation,  hypersesthesia,  and 
angesthesia  are  very  prominent.  There  is  a  dull,  aching  pain 
in  different  parts  of  the  trunk,  the  hypogastric  and  iliac  re- 
gions being  favorite  locations.  In  fact,  there  is  no  portion 
of  the  body  that  is  free  from  these  peculiar  hysterical  pains. 
Headache,  pain  in  the  eyes,  ears,  and  the  spine,  and  wander- 
ing pains,  as  they  are  called,  too,  are  common.  Sometimes 
in  hysterical  patients  they  are  really  feigned. 

The  senses  also  come  in  for  their  share  of  derangement — 
sight,  hearing,  smell,  and  taste  are  all  deranged,  and  the  di- 
gestive organs  and  function  sometimes  so  much  so  that  there 
really  is  a  hysterical  dyspepsia.  Respiration,  also,  is  often 
affected,  a  dry,  hacking  cough  being  one  of  the  most  promi- 
nent symptoms  ;  a  painful  feeling  in  the  larynx  another,  while 
globus  hystericus  is  common.  Attacks  of  rapid,  labored 
breathing,  yawning,  sneezing,  and  sighing  are  all  occasionally 
noticed.  The  circulation,  too,  is  often  involved  ;  palpitation 
of  the  heart  is  quite  common,  and  a  form  of  angina  pectoris 
is  at  times  manifested.  Disorders  of  the  secretions  are  not 
rare,  and  this  is  observed  especially  in  the  secretion  of  large 
quantities  of  limpid  urine,  which  generally  takes  place  during 
a  paroxysm  or  explosion  of  hysteria.  Sometimes  it  occurs 
after  excitement  of  any  kind.     Again,  the  secretion  is  defi- 


HYSTEEIA.  291 

cient,  there  being  partial  suppression,  which  lasts  usually  for 
a  brief  period.  Retention  of  urine  is  also  quite  common,  but 
as  this  retention  is  due  to  muscular  spasm,  it  may  be  a  purely 
nervous  perversion.  Irritation  of  the  bladder  is  frequent,  and 
a  constant  desire  to  urinate  is  one  of  the  most  persistent 
symptoms  in  hysterical  patients.  These  deranged  functions 
of  the  bladder  I  have  summed  up  in  one  expression — the  hys- 
terical bladder.  Sometimes  there  is  derangement  of  the  liver 
secretion.  ^  Lastly,  the  mammary  glands  may  be  affected,  the 
breasts  becoming  swollen,  congested,  and  secreting  milk  in 
those  who  are  not  nursing.  Hysterical  mothers,  too,  during 
lactation  are  liable  to  have  suppression  or  partial  suppression, 
and  a  change  in  the  secretion,  so  that  the  milk  becomes  un- 
wholesome or  innutritions. 

The  most  unsatisfactory  part  of  the  clinical  history  of  hys- 
teria in  regard  to  functional  derangements  is,  that  if  they 
continue  for  any  length  of  time,  or  recur  a  great  many  times, 
they  become  permanent  and  real  affections  which  will  persist 
after  the  hysteria  which  gives  rise  to  them,  or  the  deranged 
innervation  of  hysteria  producing  them,  has  subsided.  One 
peculiarity  of  all  the  functional  derangements  is  that  they 
usually  come  on  suddenly,  last  for  a  longer  or  shorter  time 
and  disappear  as  promptly  as  they  came,  and  may  recur 
again  and  again.  In  this  respect  they  differ  from  other  func- 
tional derangements  or  disorders  due  to  altogether  different 
causes  than  those  of  hysteria. 

The  first  impression  that  one  gets  from  studying  the 
symptomatology  of  hysteria  is  the  endless  variety  of  the 
symptoms,  and  it  seems  almost  impossible  to  make  them  of 
any  real  diagnostic  value.  This  arises  from  the  fact  that 
hysterical  subjects  are  the  greatest  possible  mimics,  and  their 
functional  disorders  in  the  great  majority  of  cases  are  imita- 
tions of  all  diseases  known  to  the  patient.  There  are,  how- 
ever, certain  peculiarities  of  these  symptoms  which  apply  to 
all  of  them — i.  e,,  the  suddenness  of  their  appearance  and 
their  intensity  or  severity,  their  brief  or  limited  duration,  and 
the  absence  of  any  apparent  organic  affections  to  account  for 


292  MEDICAL   GYNECOLOGY. 

them.  Bearing  these  points  in  mind,  they  become  of  value  ; 
as  they  say  in  law  that  "those  who  testify  too  much  weaken 
their  evidence,"  so  it  is  with  hysterical  patients.  They  en- 
deavor to  prove  so  much  by  their  symptoms  that  the  clever 
diagnostician  at  once  sees  proof  that  there  is  no  trouble  save 
hysteria. 

The  diagnosis  of  hysteria,  on  account  of  the  peculiarity  of 
the  clinical  history,  has  to  be  made  in  the  great  majority  of 
cases  by  exclusion.  The  skilled  and  experienced  diagnos- 
tician who  can  readily  detect  all  functional  and  organic 
diseases  excepting  those  that  are  hysterical,  can  by  careful 
elimination  prove  conclusively,  or  arrive  at  a  definite  and  posi- 
tive diagnosis  ;  and  the  ability  to  do  it  must  always  depend 
upon  skill  in  general  diagnosis.  The  differential  diagnosis 
between  this  disease  and  neurasthenia  will  be  given  hereafter. 

The  prognosis  in  hysteria  is,  as  a  rule,  favorable.  As 
patients  advance  in  life  the  nervous  system  becomes  some- 
what blunted  in  its  sensitiveness,  and  so  the  patient  can  ac- 
commodate herself  to  her  environment ;  or,  in  other  words,  the 
hysterical  personality  becomes,  through  time  and  experience, 
greatly  modified  and  imjDroved  :  this  much  as  applied  to 
ordinary  hysteria  in  its  multifarious  manifestations. 

There  remains  to  be  considered  a  form  of  hysteria  which 
in  some  of  its  characteristics  is  so  well  defined  as  to  deserve  a 
special  consideration  :  I  refer  to  hystero-epilepsy.  This  term 
is  applied  to  severe  convulsive  attacks  which  very  closely 
resemble  the  paroxysms  of  epilepsy,  and  yet  the  condition 
differs  decidedly  from  true  epilepsy,  and  only  occurs  in 
hysterical  subjects.  So  closely  did  this  form  of  hysterical 
paroxysms  resemble  true  ei)ilepsy  that  some  authorities 
believed  that  both  disorders  existed  together,  or  perhaps  it 
would  be  better  to  say  that  it  was  an  epilej^sy  in  hysterical 
subjects.  Charcot,  however,  to  whom  we  are  indebted  for 
most  of  all  that  we  know  on  this  subject,  believes  that  it  is 
pure  hysteria,  and  only  takes  on  the  semblance  of  epilepsy. 

The  peculiarities  of  hystero-epilepsy  which  help  to  dis- 
tinguish it  from  true  epilepsy  are,  that  preceding  the  attack 


HYSTERIA.  293 

there  is  usually  a  feeliug  of  general  malaise,  loss  of  appetite 
and  sometimes  nausea,  vomiting,  and  headache.  Some  are 
quiet  and  morose,  others  are  excitable  and  noisy.  If  there 
are  any  other  hysterical  derangements  of  function  they  now 
become  more  marked.  There  is  an  aura  felt  which  commonly 
begins  in  the  iliac  regions.  This  lasts  for  a  time,  and  then  the 
patients  are  seized  with  a  convulsion,  usually  with  a  feeling 
or  a  warning  that  it  is  coming,  so  that  they  generally  can 
take  care  'of  themselves.  The  convulsion  almost  invariably 
begins  as  in  true  epilepsy.  Sometimes  the  patient  screams,  is 
pale,  and,  if  standing,  falls  ;  the  body  and  limbs  become  rigid, 
and  occasionally  the  body  is  bent  backward.  According  to 
Charcot,  the  rigidity  is  seldom  followed  by  clonic  convulsions. 
At  times  the  convulsion  is  most  marked  on  one  side  of  the 
body,  as  in  true  epilepsy  ;  at  others  the  body  is  violently  con- 
torted, extraordinary  postures  being  assumed,  and  delirium 
sometimes  supervenes.  The  attack  very  often  ends  in  tears 
and  laughter,  and  after  this  the  patient  is  likely  to  remain 
melancholy.  These  attacks  may  recur  again  and  again  at 
short  intervals. 

From  Charcot  we  learn  that  the  paroxysms  are  to  be  dis- 
tinguished from  true  epilepsy  by  the  fact  that  they  can  be 
modified  or  arrested  by  compression  of  the  ovary.  I  saw 
several  cases  while  with  Charcot,  and  they  were  all  arrested 
promptly  on  very  severe  pressure  being  made  over  the  ovaries. 
The  temperature,  he  tells  us,  never  rises  above  101°  F.  or 
thereabouts,  whereas  after  a  series  of  true  epileptic  fits  a  tem- 
perature of  105°  F.  may  be  attained  and  may  continue  for  a 
time.  Perhaps  one  of  the  most  important  differentiations  is 
that  attacks  of  hystero-epilepsy  may  follow  each  other  in 
rapid  succession  until  scores  or  hundreds  occur  in  twenty- 
four  hours,  and  yet  the  patient's  general  state  is  little  affected 
thereby.  Oft-recurring  paroxysms  of  epilepsy  with  an  ac- 
companying high  temperature  place  the  patient's  general 
health  in  a  critical  condition. 

Causation. — The  hysterical  personality  is  largely  heredi- 
tary.   Mothers  of  highly  nervous  temperament — neurotic  sub- 


294  MEDICAL  GYNECOLOGY. 

jects  as  they  are  called — often  have  hysterical  daughters. 
Tubercular  mothers,  it  is  said,  may  transmit  hysteria  or  a 
hysterical  organization.  It  has  been  said,  too,  that  gouty 
subjects  may  have  hysterical  offspring.  It  would  appear, 
then,  that  not  only  is  hysteria  inherited,  but  many  other  de- 
fects or  peculiarities  of  constitution  may  be  transmitted — not 
in  their  own  form,  but  in  the  form  of  hysteria  or  the  hyster- 
ical personality.  Education,  training,  and  surroundings  have, 
no  doubt,  much  to  do  with  producing  this  imperfect  develop- 
ment which  gives  the  hysterical  tendency.  Maldevelopment 
from  improper  education,  culture,  and  general  training,  as 
has  been  pointed  out  in  the  beginning  of  this  work,  cer- 
tainly has  much  to  do  with  the  causation  of  hysteria.  The 
overdevelopment  of  the  emotions  in  petted,  "spoiled"  chil- 
dren, the  utter  neglect  of  the  motor  and  co-ordinating  facul- 
ties, and  above  all  the  example  of  associates,  are  of  importance 
in  this  direction. 

The  exciting  causes  are  strong  disturbing  external  impres- 
sions, shock  from  fear,  and  Joy  or  sorrow.  These  are  all  capa- 
ble of  bringing  out  this  latent  or  quiescent  hysteria  in  sub- 
jects predisjDOsed  to  the  malady.  Irritation  or  functional 
derangements  of  any  of  the  organs  or  tissues  of  the  body  are 
also  powerful  exciting  causes,  especially  if  the  functional  dis- 
orders are  associated  with  some  pain  and  irritation.  Severe 
or  acute  diseases  are  not  so  likely  to  excite  hysterical  par- 
oxysms or  attack.  In  fact,  hysterical  patients,  vrhen  they  are 
really  ill  and  suffering  from  any  severe  and  serious  disease, 
are  very  often  relieved  from  their  hysterical  attacks. 

Hyperactivity  of  the  nutritive  forces,  or  a  diminution  in 
the  amount  of  their  work,  are  two  conditions  of  the  nutritive 
system  which  seem  to  favor  hysteria.  It  may  be  said  that 
there  is  a  sthenic  and  an  asthenic  form  of  the  ailment,  one 
appearing  to  be  fostered  by  idleness  and  the  other  by  over 
taxation.  It  has  been  noted  that  hysteria  most  frequently 
manifests  itself  for  the  first  time  at  puberty,  at  the  time 
when  the  young  subject  is  brought  into  contact  with  new  im- 
pressions and  fresh  demands  are  made  upon  the  organization, 


HYSTERIA.  295 

and  when  tlie  evolution  of  the  sexual  organs  reacts  upon  or 
excites  the  emotions.  Hence,  improper  management  at  this 
period  of  life  often  eventuates  in  attacks  of  hysteria.  As  the 
name  implies,  the  disease  is  largely  dependent  upon  the  sex- 
ual organs  in  women,  but  I  am  satisfied  that  it  is  only  so  in 
part.  Diseases  and  functional  derangements  of  the  sexual 
organs  are  more  likely  to  produce  hysteria  than  diseases  of 
other  organs  and  tissues  of  the  body,  but  that  is  simply  due 
to  the  fact  that  the  sexual  organs  are  more  closely  allied  to 
the  organic  nervous  system  and  to  the  emotions  than  any 
others.  And  while  it  is  true  that  in  diseases  of  the  sexual 
organs,  especially  of  the  ovaries,  hysteria  is  caused  by  reflex 
influences,  it  is  far  from  being  a  fact  that  the  sexual  organs 
are  the  only  factors  in  the  causation  of  hysteria ;  they  should 
only  be  taken  as  prominently  related  to  hysteria  in  the  line 
of  causation. 

Treatment. — In  discussing  the  treatment  of  hysteria  it  is 
to  be  understood  that  I  shall  confine  my  remarks  to  the  pre- 
vention and  management  of  the  various  forms  of  this  afl'ection 
that  are  'dependent  upon  the  influence  of  the  sexual  organs  in 
health,  and  also  certain  general  diseases  of  the  sexual  organs. 
In  thus  circumscribing  the  discussion  of  the  subject  so  as  to 
keep  it  within  the  scope  of  the  present  work  a  number  of 
forms  of  hysteria  having  no  appreciable  relation  to  the  sexual 
organs  will  be  omitted.  Hysteria  being  very  largely  a  heredi- 
tary condition,  and  consequently  beyond  the  control  of  the 
physician,  nothing  need  be  said  on  this  subject.  Much  that 
will  be  said,  however,  regarding  the  management  of  hysteria 
may  ajjply  to  the  treatment  of  pregnant  women  who  are  of 
this  diathesis,  because  it  is  clear  that  during  gestation  if  the 
hysterical  mother  can  be  kept  free  from  such  attacks,  the  less 
likely  she  will  be  to  transmit  that  personality  to  her  offspring. 
Much  can  be  accomplished  in  the  management  of  children 
born  of  mothers  so  affected.  Such  girls  should  be  carefully 
watched  and  guided,  so  that,  as  far  as  possible,  they  may  at- 
tain that  kind  of  development  calculated  to  enable  them  to 
outgrow  the  hysterical  tendencies. 


296  MEDICAL  GYNECOLOGY. 

In  case  hysteria  shows  itself  in  early  life — and  this  is 
largely  due  to  the  mother  being  predisposed  to  the  trouble  by 
constitution  of  mind  and  body — every  effort  should  be  made 
to  improve  the  surroundings.  Should  this  be  found  to  be 
impossible,  as  it  ordinarily  is  at  home,  the  child  should  be  re- 
moved from  maternal  care  and  placed  under  proper  manage- 
ment either  in  a  boarding  school  or  sanitarium.  When  this 
is  not  practicable,  a  nurse  or  governess  should  be  obtained 
who  can  carry  out  the  physician's  directions.  Nothing  is 
more  important,  or  indeed  more  difficult,  to  secure  than  the 
proper  kind  of  nurse.  So  many  nurses  are  themselves  hys- 
terical that  they  are  entirely  incompetent  to  manage  young 
hysterical  subjects,  no  matter  how  skillful  in  other  cases  they 
may  be.  In  selecting  a  nurse,  then,  the  greatest  possible  care 
is  necessary.  Older  nurses  should  be  chosen — those  who 
have  had  experience  in  the  management  of  nervous  cases  and 
who  have  been  successful,  and  who  are  either  naturally  en- 
tirely free  from  hysteria  or  by  life  training  have  entirely 
overcome  such  a  tendency.  The  nurse  or  attendant  should 
kindly  but  firmly  rule  the  young  hysterical  case  and  possess 
the  power  of  diverting  the  attention  of  the  patient  from  any- 
thing that  may  excite  manifestations  of  the  affection.  One 
who  possesses  what,  in  common  parlance,  is  called  magnetism 
(which  medical  men  call  hypnotic  power)  will  be  able  to  take 
advantage  of  the  fundamental  law  of  hypnotism — suggestion 
— and  apply  it  to  advantage  in  directing  the  patient's  thoughts 
into  healthful  channels. 

Abundant  exercise  and  sufficient  rest  should  be  carefully 
regulated;  outdoor  life,  tepid  or  cold  baths,  followed  by 
brisk  rubbing,  plain,  nutritious  diet,  with  a  limited  amount 
of  animal  food,  attention  to  all  the  bodily  functions,  and, 
above  aU,  regularity  in  everything,  should  all  be  carefully 
attended  to.  In  regard  to  the  mental  training,  all  the  brain 
exercise  in  the  way  of  healthy  education  should  be  pre- 
scribed that  the  patient  can  endure.  The  moment  any  men- 
tal exercise  begins  to  cause  excitement  either  from  extreme 
interest    or    discouragement   and    irritability,   it  should  be 


HYSTERIA.  297 

stopped,  and  not  resumed  until  perfect  rest  has  been  ob- 
tained. It  is  difficult  to  regulate  the  amount  of  mental  exer- 
cise, and  it  can  only  be  done  by  careful  watching.  Any 
excitement,  either  from  work  or  amusement,  should  be  care- 
fully guarded  against.  In  short,  everything  that  is  necessary 
to  secure  health  of  body  and  mind,  and  freedom  from  excite- 
ment or  overtaxation,  should  be  secured. 

The  majority  of  cases  of  hysteria  manifest  themselves  first 
at  puberty*;  at  least  the  attention  of  the  physician  is  gener- 
ally called  to  such  cases  at  that  time.  In  discussing  puberty 
and  menstruation  the  management  has  been  given  somewhat 
at  length,  and  need  not  be  repeated  here.  Suffice  it  to  say 
that,  in  hysterical  cases  especially,  any  symptoms  that  point 
to  trouble  of  the  sexual  organs  should  be  at  once  attended  to. 

Strong,  healthy  girls  sometimes  have  dysmenorrhoea  that 
is  not  accounted  for  by  any  affection  of  the  sexual  organs,  but 
is  purely  hysterical  or  nervous  in  character.  Such  patients 
should  be  removed  from  all  ordinary  excitement,  and  still  be 
mentally  occupied  as  much  as  possible  so  as  to  divert  atten- 
tion from  the  function  of  menstruation.  When  the  dys- 
menorrhoea is  attended  with  gastric  disturbance,  such  as  nau- 
sea and  intestinal  derangement,  constipation,  or,  what  occa- 
sionally happens,  diarrhoea,  remedies  should  be  employed 
to  quell  the  nausea,  and  one  of  the  best  is  small  doses  of  bro- 
mide of  soda  with  hydrocyanic  acid.  If  there  is  diarrhoea,  it 
should  not  be  checked  unless  it  continues  more  than  twenty- 
four  hours.  If  it  does  so  and  there  is  intestinal  pain  with  it, 
the  bismuth  or  the  subgallate  of  bismuth  will  generally  give 
relief  if  given  in  connection  with  rest  and  fluid  nourishment 
in  small  quantities.  In  regard  to  constipation,  if  the  patient 
is  at  all  plethoric,  saline  laxatives  are  by  far  the  best,  espe- 
cially if  there  is  a  tendency  to  monorrhagia.  On  the  other 
hand,  if  the  patient  is  anaemic  and  menstruation  is  scanty, 
aloes  and  belladonna  in  small  doses  given  two  or  three  times 
a  day  will  give  better  results.  Many  of  the  strong,  healthy 
girls  who  are  hysterical  are  sometimes  fortunate  enough  to 
have  profuse  menstruation.     This  usually  alarms  the  patient 


298  MEDICAL  GYNECOLOGY. 

and  the  mother,  and  aggravates  the  hysterical  element.  This 
can  usually  be  set  at  rest  by  the  assurance  that  it  is  a  for- 
tunate state  of  affairs. 

I  have  observed  that  menorrhagia  or  free  menstruation  is 
a  great  safeguard  to  hysterical  women,  and  if  a  physician 
can  not  persuade  them  that  such  is  the  case,  he  may  be  able 
to  quiet  their  apprehensions  by  assuring  them  that  there  is  a 
congested  condition  which  can  only  be  relieved  by  this  free 
depletion.  In  case  it  goes  so  far  as  to  cause  any  depres- 
sion or  debility,  remedies  will  be  administered  to  control  it. 
Some  cases  really  require  treatment  for  menorrhagia ;  these 
are  easily  relieved  by  rest  in  the  recumbent  position,  but  not 
upon  the  back,  and  should  be  allowed  to  get  up  and  move 
about  for  a  short  time  repeatedly  during  the  day,  five  to  ten 
drops  of  the  flaid  extract  of  hydrastis  canadensis  being  ad- 
ministered before  meals.  All  animal  food  should  be  inter- 
dicted, highly  seasoned  articles  of  food,  and  especially  all  al- 
coholic stimulants.  In  case  this  ordinary  management  does 
not  entirely  relieve  the  hysteria  and  nerve  perturbations, 
bromides  should  be  given  to  the  strong  and  full-blooded,  and 
camphor  and  asafoetida  to  the  asthenic  patients. 

It  not  infrequently  happens  that  at  puberty  and  for 
months  afterward  hysterical  patients  complain  of  backache 
and  intermittent  leucorrhoea,  or  leucorrhoea  with  usually  a 
free  secretion  of  the  vulvo-vaginal  glands,  frequent  urination, 
and  a  sense  of  heat  and  fullness  in  the  pelvis.  These  symp- 
toms indicate  nothing  more  than  a  physiological  condition 
due  to  deranged  innervation.  Young  hysterical  subjects  hav- 
ing their  attention  called  to  the  sexual  organs  by  the  advent 
of  the  menstrual  function  are  very  apt  to  give  undue  atten- 
tion to  the  sexual  organs.  They  notice  the  slightest  symp- 
tom, magnify  it,  dwell  upon  it,  and  so  increase  the  deranged 
innervation  ;  and  mothers  frequently  bring  their  daughters  to 
the  physician  complaining  in  this  way  and  are  rather  urgent 
to  have  something  done,  fearing  that  they  have  some  very 
serious  womb  or  ovarian  trouble.  The  patients  themselves, 
especially  those  who  have  studied  enough  of  anatomy  and 


HYSTERIA.  299 

physiology  in  high  school  or  college,  are  often  very  positive 
that  they  have  some  serious  trouble.  Such  cases  should,  if  it 
is  at  all  possible,  be  relieved  by  general  management,  and  any 
local  examination  or  local  treatment  should  be  avoided. 

I  know  of  nothing  more  prejudicial  than  local  examina- 
tions for  supposed  pelvic  affections  in  hysterical  girls.  I  in- 
sist upon  it,  then,  that  no  examination  should  ever  be  made 
unless  the  symptoms  point  beyond  doubt  to  some  organic 
affection,  ^nd  not  until  every  effort  has  been  made  by  the 
physician  to  give  relief.  I  have  seen  mild  cases  of  hysteria 
aggravated  and  confirmed  hysterical  subjects  made  by  phys- 
ical examination  of  the  pelvic  organs.  So  strongly  am  I  con- 
vinced of  the  perniciousness  of  this  practice  that  I  have  for  a 
long  time  absolutely  refused  to  examine  such  cases,  except 
under  an  anaesthetic,  and  then  not  until  I  was  perfectly  satis- 
fied that  all  efforts  in  the  way  of  medication  and  general  man- 
agement failed  to  give  relief,  and  consequently  that  there  must 
be  some  important  organic  disease  which  required  local  treat- 
ment. 

I  may  give  one  case  selected  from  a  large  number  that  will 
illustrate  this  point.  A  hysterical  mother  brought  her  daugh- 
ter, who  was  similarly  afflicted,  to  see  me.  They  were  both 
in  tears,  the  mother  terrified  by  her  daughter's  condition,  and 
the  daughter  fully  persuaded  that  she  was  very  dangerously 
ill.  Apart  from  her  hysteria  she  was  somewhat  anaemic  ;  her 
digestion,  while  not  bad,  was  slightly  impaired ;  she  men- 
struated irregularly,  going  over  her  time  usually  for  a  week  ; 
the  flow  lasted  a  shorter  time  than  usual,  and  she  had  back- 
ache, or  rather  she  had  pain  in  her  spine  at  various  points, 
which  was  continuously  changing.  She  had  occasional  leu- 
corrhoea,  with  a  sense  of  fullness,  heat,  or  congestion  about 
the  vulva.  At  times  she  had  very  frequent  urination,  but 
usually  was  able  to  sleep  through  the  night  without  micturat- 
ing. I  assured  both  the  patient  and  her  mother  that  she  had 
no  local  disease  whatever,  and  that  all  her  ill  feelings  were 
due  to  her  depleted  condition  and  overexcitement  and  anxi- 
ety, and  prescribed  for  her  hysteria,  putting  her  upon  tonics, 

20 


300  MEDICAL  GYNECOLOGY, 

sedatives,  nourishing  food,  and  above  all  things  insisting  that 
she  should  go  to  boarding  school  or  somewhere  that  she  might 
be  under  the  care  of  a  proper  nurse  or  governess.  This  part 
of  the  treatment  they  declined  to  follow  out ;  everything  else, 
however,  was  attended  to  as  best  they  could.  I  insisted  that 
the  mother  should  treat  her  daughter,  not  as  an  invalid  or 
sick  person,  but  as  a  nervous,  hysterical  girl.  This  she  tried 
to  do,  but,  being  hysterical  herself,  failed. 

At  my  second  visit  there  was  some  improvement,  but  not 
much.  I  saw  nothing  more  of  her  for  a  year,  when  I  hap- 
pened to  meet  the  young  lady  by  accident,  and  she  hastened 
to  tell  me  that  I  made  a  mistake  in  her  case  when  I  said  there 
was  nothing  the  matter  with  her  womb  and  ovaries  ;  that  she 
had  gone  to  another  doctor,  who  had  examined  her  and  found 
that  her  uterus  was  tipped,  and  that  there  was  a  good  deal  of 
inflammation.  She  assured  me  that  the  inflammation  was 
there,  because  the  examination  hurt  her  so  dreadfully  that 
she  had  a  fainting  attack  and  was  delirious  all  day,  and  was 
unable  to  get  out  of  bed  for  several  days.  Certain  treatment 
was  employed  once  or  twice  a  week  for  about  threq^  weeks. 
At  that  time  she  was  very  much  worse  than  she  had  been,  but 
the  doctor  assured  her  that  he  had  overcome  the  difficulties 
(local  trouble),  and  that  when  she  got  strong  she  would  be 
entirely  well. 

It  is  some  time  since  all  this  happened — a  couple  of  years, 
I  think — but  she  is  still  an  invalid,  or  fancies  that  she  is  ;  and 
I  am  perfectly  confident  that  if  she  could  have  been  j)ut  under 
proper  care  and  her  jDelvic  organs  left  severely  alone,  by  her- 
self and  her  medical  attendants,  she  would  have  been  well. 
I  base  this  opinion  upon  the  fact  that  I  have  treated  many 
such  cases  medically,  and  they  comx^letely  recovered.  But, 
what  is  more  important,  I  learned  from  the  doctor  who 
treated  her  locally  that  he  really  did  not  find  anything  the 
matter  with  her,  unless  it  was  a  congestion. 

Tampering  with  the  pelvic  organs  when  there  is  nothing 
the  matter  with  them  increases  hysteria  tenfold,  as  we  might 
rationally  suppose.     On  the  other  hand,  in  young  subjects, 


HYSTERIA.  301 

even  if  there  is  some  actual  disease,  whether  of  the  ovaries 
or  of  the  uterus,  that  can  be  relieved  by  local  treatment,  it  is 
generally  well  borne,  and  the  patient's  hysterical  symptoms 
are  usually  relieved.  In  older  patients  who  have  uterine 
disorders  I  have  found  that,  as  a  rule,  when  protracted  local 
treatment  is  employed,  the  results  are  very  favorable,  and 
the  effect  upon  the  hysterical  condition  beneficial.  The  dan- 
ger which  the  physician  must  at  all  times  guard  against  is  not 
to  be  persuaded  to  make  local  examinations  or  employ  local 
treatment  in  cases  of  feigned  diseases  of  the  sexual  organs  so 
common  among  patients  suffering  from  this  imitative  disease. 

The  direct  or  special  treatment  of  hysteria  itself,  after  all 
the  known  causes  are  removed,  are  tonics  and  sedatives  es- 
pecially. The  strong  or  full-blooded  patients  require  hydro- 
pathic treatment,  bromides,  and  active  exercise,  as  well  as 
occupation  of  body  and  mind.  The  asthenic  or  debilitated 
do  better  upon  tonics  and  electricity.  Tonics  such  as  quinine, 
iron,  strychnine,  and  the  salts  of  zinc  answer  best.  Anti- 
spasmodics have  also  been  used  from  time  immemorial ;  the 
best  of  these,  no  doubt,  is  asafoetida,  although  camphor, 
valerian,  and  ammonia  are  good.  Sedatives  are  not  always 
competent  to  produce  sleep,  and  so  anodynes  become  neces- 
sary. Opium,  of  course,  should  be  avoided.  Camphor  and 
lupulin,  sometimes  camphor,  lupulin,  and  a  little  belladonna, 
will  give  sleep.  Sulphonal  and  phenacetine,  with  the  addition 
of  caffeine,  answers  well  in  some  cases,  but  not  in  all. 

In  all  the  treatment  of  hysteria  the  physician  must  have 
the  patient's  entire  confidence,  and  his  rulings  must  be  absolute 
and  accurate,  as  the  disease  is  often  produced  and  aggravated 
by  suggestion,  so  that  important  element  of  hypnotism — sug- 
gestion or  mental  influence  of  the  attending  physician — is  the 
most  potent  remedial  agent  of  all  in  hysteria.  Some  prac- 
titioners endeavor  to  rule  those  patients  with  a  rod  of  iron, 
and  there  are  some  who  will  submit,  but  the  great  majority 
of  them  rebel,  and  it  is  better  to  lead  quietly  than  to  drive. 
It  is  in  the  management  of  the  low  class  of  cases  that  the 
personnel  of  the  physician  is  of  so  much  value.     Some  prac- 


302  MEDICAL  GYNECOLOGY. 

titioners  are  nnable  to  manage  hysterical  cases,  while  others 
have  a  wonderful  facility  in  doing  so ;  the  same  may  be  re- 
marked of  nurses. 

The  treatment  of  violent  paroxysms  of  hysteria  and  hys- 
tero-epilepsy,  as  it  is  called,  requires  more  than  a  passing 
notice.  While  the  improvement  of  the  general  health,  anti- 
spasmodic tonics,  general  hygiene,  and  mental  training  all 
apply  in  cases  of  hystero-epilepsy,  there  still  remains  to  be 
considered  the  management  of  the  patient  while  in  parox- 
ysms or  convulsions.  It  has  been  already  stated  that  Char- 
cot found  that  the  paroxysm  of  hystero-epilepsy  could  often 
be  relieved  or  arrested  completely  by  pressure  upon  the 
ovaries.  This  is  true,  no  doubt,  but  I  do  not  believe  it  is  be- 
cause of  any  beneficial  effect  of  pressure  upon  the  ovaries.  I 
think  it  is  simply  an  impression  which  acts  more  after  the 
fashion  of  hypnotism  by  suggestion.  I  have  been  led  to  this 
belief  from  the  history  of  one  or  two  cases  that  I  saw  early 
in  my  career  ;  in  fact,  they  were  hospital  patients  of  mine  be- 
fore anything  was  known  definitely  about  hystero-epilepsy. 
One  was  a  young,  vigorous,  hysterical  girl,  who  was  brought 
into  the  hospital  by  the  police  department,  having  been  found 
in  the  street  in  an  epileptiform  convulsion.  As  I  remember 
her  now,  she  was  a  typical  case  of  hystero-epilepsy.  It  was 
the  belief,  however,  that  she  was  a  true  epileptic.  The  house 
surgeon,  who  had  quite  an  interest  in  her  case,  discovered 
that  he  could  break  up  her  convulsion  by  putting  aromatic 
spirits  of  ammonia  upon  his  hand  and  placing  it  over  her 
mouth  and  nose,  I  had  occasion  to  see  him  treat  her,  for  he 
was  quite  proud  of  his  discovery,  but,  believing  that  the  case 
was  hysterical  and  that  this  treatment  was  merely  an  impres- 
sion or  suggestion,  I  tried  putting  my  hand  over  her  mouth 
and  nose  without  ammonia,  and  found  it  had  the  same  effect. 
He  also  tried  it,  and  found  the  same  result.  It  was  noticed, 
however,  that  when  the  ammonia  was  not  used  she  was  likely 
to  have  a  relapse. 

In  another  case,  under  the  care  of  an  acquaintance,  when 
he  was  first  called  to  see  the  patient  and  found  her  in  a  vio- 


HYSTERIA.  303 

lent  paroxysm,  he  made  pressure  over  the  carotid  arteries 
and  the  convulsion  at  once  stopped.  He  directed  some  mem- 
ber of  the  family  how  to  do  it,  and  every  time  the  convulsion 
occurred  pressure  was  made  and  the  paroxysm  was  arrested. 

Again,  a  powerful  impression  made  by  dashing  cold  water 
on  the  head,  or  keeping  up  a  continuous  douche  of  it  on 
that  part,  will  break  up  the  paroxysm  without  harm.  The 
inhalation  of  ammonia  or  camphor  sometimes  will  have  the 
like  effect.  Perhaps  the  most  powerful  agent,  and  one  that 
not  only  breaks  up  the  paroxysm  but  is  curative  to  a  certain 
extent,  is  an  emetic.  While  a  student  of  medicine,  the  pro- 
fessor of  therapeutics  recommended  tartar  emetic  in  the  treat- 
ment of  hysterical  convulsions,  and  soon  after  engaging  in 
practice  I  had  occasion  to  try,  not  tartar  emetic,  but  an  emetic 
dose  of  ipecac. 

A  young  married  woman,  strong,  vigorous,  full-blooded, 
and  hysterical,  discovering  what  she  supposed  to  be  a  little 
attention  on  the  part  of  her  husband  to  a  neighboring  lady, 
declared  that  she  would  not  live  under  such  conditions,  and 
that  she  had  taken  poison.  She  was  heard  to  exclaim,  "IN'ow 
I  have  done  it !  "  then  threw  a  bottle  on  the  grate  and  broke 
it,  and  went  off  immediately  into  a  violent  convulsion.  A 
messenger  came  for  me  and  told  me  the  circumstances  and  I 
was  soon  at  her  bedside,  and  found  her  violently  convulsed, 
but  the  character  of  the  convulsion  was  hysterical.  I  doubted 
the  fact  of  her  having  taken  poison,  but  as  her  friends  in- 
sisted upon  it,  and  thought  it  quite  proper  to  administer  an 
emetic,  I  did,  giving  her  a  large  dose  of  ipecac,  either  the  wine 
or  sirup,  or  equal  parts  of  each,  which,  I  am  unable  to  re- 
member at  this  moment.  The  result  was  that  the  convulsion 
was  broken  up,  and,  so  far  as  I  know,  she  has  never  had  an- 
other. It  was  exceedingly  beneficial.  She  was  very  sick  after 
the  emetic,  and  remained  so  long  enough  to  give  her  time  for 
reflection.  I  think  she  saw  the  folly  of  her  behavior,  espe- 
cially as  I  had  standing  orders  that,  if  she  showed  the  slight- 
est disposition  to  have  any  more  trouble  of  the  kind,  she 
should  at  once  be  given  a  dose  of  the  same  medicine. 


CHAPTER  XXy. 

NEUEASTHElSriA. 

This  is  an  exhaustion  of  the  nervous  system,  due  no  doubt 
to  malnutrition.  Many  names  have  been  applied  to  this  af- 
fection, such  as  nervous  exhaustion,  nervous  debility,  and 
nervous  prostration.  I  prefer  neurasthenia,  in  compliment 
to  my  friend  the  late  Dr.  George  M.  Beard,  whom  I  greatly 
admired.  My  attention  was  first  directed  to  the  subject  in  a 
comprehensive  way  at  a  time  when  Dr.  Beard  was  working 
up  the  subject,  when  I  saw  much  of  him.  For  a  time  he  at- 
tended my  clinics,  and  used  electricity  in  the  treatment  of 
many  of  my  cases ;  and  I  learned  from  him  much  of  the  char- 
acter of  this  neurasthenia,  and  of  the  use  of  electricity  in  its 
treatment  as  in  the  treatment  of  diseases  of  the  sexual  organs 
generally. 

Neurasthenia  usually  occurs  in  early  and  middle  life. 
There  are  two  forms,  apparently :  in  one  there  seems  to  be 
hypergemia  of  the  nerve  centers ;  in  the  other  there  are  evi- 
dences of  exhaustion  from  malnutrition,  as  well  as  dilitation 
of  the  vessels. 

The  symptoms  are,  to  a  large  extent,  the  same  in  all  cases, 
and  it  occasionally  occurs  as  a  primary  affection.  Quite 
often  it  is  due  to  other  diseases ;  and  in  turn,  when  it  occurs 
as  a  primary  aifection  and  is  permitted  to  exist  for  any  great 
length  of  time,  it  leads  to  other  diseases,  functional  for  the 
most  part.  According  to  Charcot,  neurasthenia  may  become 
hysteria  and  hysteria  neurasthenia,  a  hybrid  form  partaking 
of  the  nature  of  both  diseases,  and  known  as  hystero-neuras- 
thenia.     Lowenfeld,  of  Munich,  one  of  the  best-informed  men 

304 


NEURASTHENIA.  305 

on  the  subject  of  neurasthenia,  claims  that  there  is  such  a 
hybrid.  It  is,  perhaps,  best  to  let  this  disease  describe  itself, 
noting  its  most  prominent  symptoms.  I  might  say,  however, 
right  here,  that  some  authors  claim  that  neurasthenia  may  be 
limited  to  the  brain  or  to  the  spinal  cord,  or  that  it  may 
exist  in  both.  In  the  practice  of  gynecology  I  have  never 
been  able  to  make  these  distinctions,  but  have  usually  found 
that  the  cerebro- spinal  and  nervous  systems  are  about  equally 
involved. »  The  cerebral  symptoms  are,  first,  diminished  brain 
strength  ;  there  is  marked  loss  of  mental  concentration,  and 
the  memory  is  defective  or  impaired  ;  but  this  is  apparently 
due  to  want  of  attention  or  imperfect  perception.  There  is 
almost  always  increased  irritability  or  excitability,  manifested 
by  increased  desire  for  mental  work  or  activity,  with,  how- 
ever, diminished  ability.  The  mental  excitability  is  most 
marked  in  those  cases  where,  presumably,  there  is  a  hyper- 
semic  condition.  In  some  others  there  is  simply  loss  of  brain 
strength  without  much  irritability  or  excitability.  In  the  lat- 
ter class  the  brain  power  is  usually  at  its  lowest  ebb  in  the 
morning  and  early  part  of  the  day,  but  after  getting  thor- 
oughly wrought  up  with  the  duties  of  the  day  considerable 
brain  power  is  manifested— in  fact,  the  mind  sometimes  ap- 
pears to  be  unduly  brilliant ;  but  this  activity  is  followed  by 
an  early  and  marked  depression. 

Subjects  complain  of  unpleasant  feelings  in  the  head  with- 
out pain,  which  is  peculiarly  characteristic  of  nervous  exhaus- 
tion. This  may  be  due  in  part  to  the  fact  that  nervous  pa- 
tients notice  their  feelings  or  symptoms,  and  are  far  more  liable 
to  exaggerate  them  by  thinking  of  them.  This  introspection, 
already  discussed,  causes  depression  oftener  than  too  much 
brain  work.  Brain  work  invariably  increases  all  those  un- 
pleasant feelings,  such  as  fullness  in  the  head  and  the  feel- 
ing of  heat  and  pressure  on  the  top  of  the  head.  This  pres- 
sure on  the  top  of  the  head  was  said  by  the  older  authorities 
to  be  indicative  of  uterine  disease,  but  it  is  of  less  diagnostic 
value  in  pelvic  affections  than  in  neurasthenia ;  for  it  is  sel- 
dom present,  no  matter  how  severe  the  pelvic  disease  may  be. 


306  MEDICAL  GYXECOLOGY. 

nnless  there  is  neurasthenia  accompanying  it.  Many  of  these 
symptoms  may,  no  doubt,  be  present  in  i^erfect  health,  but 
pass  unnoticed  except  in  nervous  patients.  Dizziness  is  a 
symptom  Avhich  is  of  importance,  and  is  very  frequently 
present  in  cases  of  neurasthenia  accompanied  by  uterine  or 
ovarian  disease,  especially  in  functional  exhaustion  of  these 
organs.  As  a  rule,  the  pupils  are  dilated  ;  occasionally  they 
are  not — in  fact,  where  hypereemia  is  present  they  never  are. 
The  eyes  are  weak,  and  there  is  generally  a  sense  of  heat, 
burning,  and  smarting  in  them,  with  a  certain  degree  of 
photophobia. 

In  recent  days  a  great  deal  of  attention  has  been  given— 
in  fact,  overmuch  by  some — to  defective  vision,  which,  it  is 
claimed,  accounts  for  this  weakness,  and  is  put  down  as  a 
very  important  cause  of  neurasthenia.  There  is  doubtless 
something  in  this,  but  I  am  satisfied  that  it  has  been  grossly 
exaggerated  :  for  I  have  known'  a  number  of  cases  that  have 
been  operated  upon  again  and  again  by  the  highest  authori- 
ties under  this  class  of  oculists  without  deriving  the  slightest 
benefit,  yet  have  promptly  recovered  the  full  power  of  their 
eyes  when  they  were  relieved  of  their  local  diseases  and  had 
their  general  nerve  strength  restored.  I  think  it  is  always 
wise,  however,  when  the  eyesight  is  much  complained  of,  to 
have  the  eyes  thoroughly  examined  by  an  oculist  who  has 
not  been  carried  away  by  the  present  popular  craze  that 
nearly  all  the  ills  that  the  nervous  system  is  heir  to  arise 
from  myopia,  presbyopia,  or  some  other  defective  condition. 

The  hearing  is  sometimes  disturbed  ;  occasionally  it  is  ab- 
normally acute,  so  that  noises  are  extremely  disturbing.  Some 
suffer  from  tinnitus,  and  in  extreme  cases  there  are  confused 
murmurs  and  imaginary  sounds  heard.  Timidity  or  want  of 
courage  is  perhaps  one  of  the  most  prominent  symptoms ; 
especially  is  this  the  case  when  the  nervous  affection  is  due 
to  or  associated  with  uterine  or  ovarian  diseases.  This  timid- 
ity leads  to  apprehensions  of  all  kinds  ;  a  fear  that  tran- 
scends so  far  ordinary  feminine  fear  that  it  is  decidedly  mor- 
bid and  symptomatic  of  neurasthenia. 


NEURASTHENIA.  307 

Disturbed  or  imperfect  sleep  is  a  prominent  symptom.  In 
one  variety  the  patient  is  usually  able  to  go  to  sleep  but  soon 
wakes  before  being  refreshed,  and  failing  to  sleejD  again,  she 
does  not  get  sufficient  rest.  Others  have  the  greatest  difficulty 
in  securing  sleep,  but  when  once  they  succeed  it  is  difficult  to 
awake  them.  They  get  the  credit  of  being  lazy  in  the  morn- 
ing. It  is  important  to  note  the  distinction,  because  when 
we  come  to  discuss  the  treatment  of  insomnia  it  is  very  neces- 
sary to  make  these  clear  distinctions  in  order  to  succeed. 

This  sleeplessness  or  insomnia  is  usually  attended  with 
drowsiness  during  the  day  and  disposition  to  sleep ;  in  fact, 
the  patients  sometimes  drop  off  to  sleep  in  the  chair  or  even 
while  talking,  but  almost  immediately  awaken.  Indeed,  such 
cases  when  they  undertake  to  sleep  or  indulge  the  feeling  of 
drowsiness  at  once  become  wide  awake  on  lying  down.  The 
motor  faculty  is  also  impaired.  There  is  usually  decided 
muscular  weakness,  so  that  active  exercise  soon  exhausts. 
In  some  there  is  a  great  dislike  to  exercise  ;  others  are  irrita- 
ble, and  anxious  to  do  a  great  deal  of  walking  and  moving 
about,  but  become  exhausted  and  greatly  depressed  because 
they  are  unable  to  do  more.  Along  with  this  there  is  im- 
paired co-ordination,  so  that  the  patient  stumbles,  drops 
things  held  in  the  hand,  and  is  generally  awkward. 

Certain  vaso-motor  disturbances  are  also  noticed  ;  sudden 
flushing  of  the  face  or  blushing  on  the  slightest  provocation  ; 
the  hands  and  feet  are  apt  to  be  cold  and  clammy,  and  red 
spots  appear  on  the  neck  and  face  under  the  slightest  mental 
excitement.  This  I  have  noticed,  too,  in  a  wonderful  degree 
while  giving  ether  to  neurasthenic  i^atients.  The  neck  and 
face  and  chest  became  spotted  to  a  remarkable  extent.  Sweat- 
ing as  a  symptom  is  important  and  very  common,  and  patients 
are  very  apt  to  perspire  profusely  on  the  slightest  mental  or 
muscular  exertion.  I  find,  too,  that  they  are  apt  to  break 
out  in  perspiration  on  retiring  at  night,  an  annoying  symp- 
tom which  is  frequently  added  to  insomnia.  The  symptoms 
manifested  by  the  digestive  organs  might  be  summed  up  in  a 
word  by  saying  that  they  suffer  from  those  of  nervous  dys- 


308  MEDICAL  GYNECOLOGY. 

pepsia — that  is  to  say,  the  appetite  is  capricious,  sometimes 
abnormal  in  regard  to  the  choice  of  food,  and  attended  with 
morbid  cravings  not  unlike  those  that  occur  in  pregnancy. 
These  patients  are  nearly  always  constipated  and  suffer  great- 
ly from  flatulence. 

The  respiratory  system  shares  in  the  general  debility,  and 
one  symptom  is  especially  worthy  of  notice.  On  lying  down, 
the  patient  often  complains  of  a  feeling  of  suffocation ;  it  is 
an  asthmatic  feeling,  but  without  the  asthmatic  breathing. 
The  circulation  is  easily  disturbed  by  mental  or  physical  ac- 
tion, and  they  almost  always  suffer  from  attacks  of  palpita- 
tion, intercostal  neuralgia,  and  occasionally  angina  pectoris. 
The  urinary  organs  are  sometimes  affected ;  now  there  is 
polyuria,  and  again  the  urine  is  scanty  and  high-colored. 
The  passing  of  large  quantities  of  limpid  urine  is,  I  think,  as 
common  to  neurasthenia  as  it  is  to  hysteria.  Very  often 
there  is  irritability  of  the  bladder. 

Concerning  the  function  of  the  sexual  organs,  we  find,  in 
cases  of  exhaustion  pure  and  simple,  that  there  is  generally  a 
decline  in  the  sexual  appetence,  so  that  their  social  duties 
are  often  irksome,  sometimes  repugnant.  In  the  other  class, 
with  exhaustion  and  a  hypersemic  state  of  the  nerve  centers, 
there  is  often  a  heightened  sexual  irritability  ;  such  patients 
are  prone  to  overindulgence,  which  only  aggravates  the  neur- 
asthenia, or,  if  this  is  avoided,  they  are  disturbed  at  night 
by  troubled  and  polluted  dreams.  The  symptoms  that  so  far 
have  been  given  are,  as  a  rule,  intensified  during  menstru- 
ation, and,  strange  as  it  may  appear,  those  who  menstruate 
scantily  suffer  most.  There  are  a  few,  and  usually  those  who 
have  some  uterine  disease,  that  are  relieved  by  a  free  men- 
struation. 

The  diagnosis  is  made,  and  with  no  great  difiiculty,  by  ex- 
clusion. If  there  are  no  evidences  of  organic  disease  of  the 
nervous  system  or  of  the  organs  of  general  nutrition  and 
locomotion,  the  diagnosis  then  rests  between  neurasthenia 
and  hysteria,  and  it  is  not  difficult  to  differentiate  between 
the  two. 


NEURASTHENIA.  309 

In  hysteria  the  symptoms  constantly  change,  while  in 
neurasthenia  they  are  the  same,  or  vary  but  slightly.  In 
the  former  there  is  not  necessarily  that  muscular  feebleness 
always  found  in  true  forms  of  the  latter.  In  hysteria  the  at- 
tacks are  intermittent,  there  being  intervals  of  apparent  per- 
fect health,  while  the  patient  in  neurasthenia  is  continuously 
ill.  Influences  from  without  change  and  even  do  away  with 
symptoms  in  the  first,  while  in  the  last  the  symptoms  are 
little  if  any  altered  on  suggestion.  Diverting  the  attention  in 
hysteria  often  breaks  up  an  attack,  but  in  neurasthenia  the 
symptoms  are  more  likely  to  be  aggravated  by  anything  that 
sets  the  mind  to  work.  Hysterical  patients  give  a  history  of 
repeated  previous  attacks,  while  the  neurasthenic  do  not. 
There  is  a  violence  and  an  exaggeration  in  hysterical  attacks 
absent  in  neurasthenia. 

Causation. — Venereal  excess,  especially  when  means  of 
preventing  conception  are  employed,  induces  neurasthenia — 
not  so  much  from  extreme  indulgence  in  this  function  as  from 
the  accompanying  wear  and  tear  on  the  nervous  system  from 
anxiety,  depression,  and  perhaps  an  ever-present  sense  of 
wrongdoing.  Sexual  starvation,  by  keeping  up  undue  excita- 
tion, leads  to  nervous  exhaustion.  Sterility  in  those  who  are 
extremely  fond  of  children  often  tortures  women  into  a  con- 
dition of  exhaustion.  Exhausting  diseases  of  the  sexual  or- 
gans are  made  doubly  so  because  they  give  rise  to  so  much 
anxiety  and  apprehension.  This  is  the  case  more  so  than  in 
painful  and  serious  affections  affecting  the  nutritive  system. 
The  incapacity  which  deters  the  patients  from  taking  active 
exercise  adds  to  the  irritability  and  exhausting  worriment. 
Very  ambitious  women  feel  greatly  annoyed  when  they  are 
incapacitated  either  for  active  employment  or  enjoyment  in 
the  way  of  agreeable  entertainments.  In  the  order  of  develop- 
ment I  have  generally  found  that  first  comes  oppression  or 
depression ;  this  leads  to  malnutrition,  and  finally  to  nerve 
starvation  or  exhaustion. 

The  predisposing  causes  are  temperament,  heredity,  and 
environment.     Those  of  the  nervous  temperament — the  sensi- 


310  MEDICAL  GYNECOLOGY. 

tlfs — are  predisposed  to  neiirasthenia  only  because  they  are 
more  liable  to  overmental  exertion.  Heredity,  no  doubt,  has 
much  to  do  in  the  matter,  and  those  of  the  neuropathic  ten- 
dency are  more  liable  to  break  down  in  the  race  of  life.  It  is 
certain  that  environment  is  partly  responsible  for  predisposi- 
tion ;  and  climate,  occupation,  and  social  position  may  tend 
to  produce  neurasthenia.  The  direct  causes,  too,  are  often 
found  in  environment.  AYe  speak  of  neurasthenia  as  being 
due  to  overwork,  especially  brain  work,  but  I  am  satisfied 
that  it  is  due  far  more  to  anxiety  and  worry.  Work  does  not 
wear  out  the  machinery  ;  work  pure  and  simjole  never  hurt 
any  one.  It  is  the  jarring  and  friction  which  come  from  over- 
excitement  and  overanxiety  that  do  this ;  and  when  they  in 
turn  lead  to  errors  in  diet  and  rest,  nervous  exhaustion  fol- 
lows as  the  consequence. 

Treatment. — Trousseau  attributes  to  a  great  naturalist  the 
statement  that  "the  animal  lives  for  the  nervous  system," 
and  he  deduces  from  this  profound  saying  the  fundamental 
principle  which  he  thinks  ought  to  guide  us  in  therapeutics. 
The  therapeutic  indication  in  the  treatment  of  this  affection 
of  the  nervous  system,  and  indeed  in  nearly  all,  is  to  restore 
the  nutrition.  In  the  general  management  of  the  cases  now 
under  consideration  the  nervous  system  demands  a  large 
share  of  attention,  and,  happily,  the  resources  of  our  art  have 
been  greatly  developed  in  this  department  within  a  few  years. 
No  longer  ago  than  the  time  when  I  was  a  student  of  medi- 
cine asafoetida  and  valerian  were  the  chief  remedies  given  to 
nervous  women,  so  called,  and  if  these  did  not  cure  them,  a 
change  of  air  was  advised  as  a  last  resort.  Now  all  this  is 
changed  for  the  better,  and  the  progress  made  has  been 
chiefly  through  the  labors  of  neurologists.  It  does  not 
appear  that  so  much  has  been  accomplished  by  the  gynecolo- 
gists in  this  direction,  except  that  the  most  advanced  among 
them  have  been  sagacious  enough  to  take  advantage  of  the 
therapeutics  developed  by  those  s^Decially  interested  in  the 
nervous  system  and  its  diseases.  This  is  very  often  the  most 
difficult  thing  to  accomplish.     In  exhausted  conditions,  un- 


NEURASTHENIA.  311 

attended  with  great  irritability,  all  that  is  necessary  is  to 
secure  quiet  by  seclusion. 

Those  suffering  from  nervous  exhaustion  require  rest. 
This  can  be  accomplished  by  removing  the  patient  from  the 
cares  of  life,  whether  those  of  the  government  of  a  family 
and  household,  or  the  duties  of  a  profession  or  a  business. 
Isolation  is  to  be  secured,  and  that  for  a  time  is  all  that  is 
required  in  some  cases.  Those  who  are  exhausted  without 
being  irritable  will  rest  if  they  get  a  chance,  but  the  majority 
require  more  than  that.  Many  who  require  extra  sleep  are 
sleepless.  They  ought  to  be  quiet,  but  prefer,  in  fact  insist 
upon,  keeping  on  the  "go,"  to  obtain  relief  from  the  tortures 
of  nervous  irritability  which  appear  to  them  to  be  aggravated 
by  repose.  Such  patients  require  to  be  toned  down  to  the 
point  of  repose.  Quiet  surroundings  and  a  nurse  who  under- 
stands her  business  will  do  much  to  effect  this,  yet  medicines 
are  often  necessary.  Having  secured  the  conditions,  the  next 
requisite  is  to  obtain  sleep  without  resorting  to  opium, 
chloral,  cocaine,  or  the  like. 

In  dealing  with  those  who  are  irritable,  and  presumably 
suffering  from  congestion  of  the  nerve  centers,  bromides  are 
of  great  value.  I  might  modify  the  saying  of  Sancho  Panza 
and  render  it,  "  Bless  the  man  who  invented  the  bromides  !  " 
They  are  a  great  boon  in  the  management  of  such  cases. 
This  is  so  well  known  that  I  need  only  add  that,  in  my  obser- 
vations, I  have  found  that  it  is  best  to  push  the  bromides 
carefully,  bnt  toward  their  full  and  specific  effect,  and  to  do 
this  safely  small  doses  of  nux  vomica  should  at  the  same  time 
be  given.  While  advocating  the  liberal  use  of  bromide,  I 
would  say  it  should  not  be  long  continued.  I  rarely  give  the 
drug  longer  than  a  week  or  at  most  two,  except  perhaps  one 
dose  in  the  evening  to  prolong  the  night's  sleep.  This  an- 
swers best  in  those  cases  where  the  patients  go  to  sleep  at 
the  proper  time  without  much  trouble,  but  waken  after  an 
hour  or  two  and  fail  to  get  any  more  sleep.  The  formula 
which  I  prefer  is :  Bromide  of  soda,  one  ounce  ;  tincture  of 
nux  vomica,  two  drachms ;  essence  of  pepsin,  two  ounces ; 


312  MEDICAL  GYNECOLOGY. 

peppermint  water,  one  ounce.  Of  tMs,  a  drachm  to  be  given 
three  times  a  day  before  meals  and  at  bedtime. 

When  this  preparation  is  not  well  borne,  or  does  not  ac- 
complish the  object,  I  give  the  following  mixture :  Tincture 
of  conium,  one  ounce ;  camphorated  water,  six  ounces,  of 
this,  giving  two  teaspoonfuls  at  noon,  evening,  and  bedtime. 
In  place  of  this  I  have  used,  tincture  of  lupulin,  one  drachm, 
tincture  of  belladonna,  two  drachms  ;  tincture  of  cardamom, 
three  ounces,  giving  a  teaspoonf  ul  at  noon,  evening,  and  bed- 
time. In  the  case  of  one  patient,  when  all  of  these  had  failed, 
I  got  the  desired  effect  by  giving  two  grains  of  croton  chloral 
three  times  a  day — at  noon,  evening,  and  bedtime. 

All  of  these  I  consider  as  substitutes,  to  be  used  in  rare 
cases  when  the  bromides  fail. 

Alcoholic  stimulants  may  be  named,  but  to  say  that,  as  a 
rule,  they  are  not  well  borne.  While  they  may  quiet  the 
nervous  symptoms  for  a  time,  the  effect  upon  the  pelvic  or- 
gans is  usually  unfavorable,  and  there  is  often  a  reaction 
which  is  not  satisfactory,  so  that  what  is  gained  in  one  direc- 
tion is  lost  in  another.  I  must  say,  however,  that  in  certain 
cases  of  extreme  exhaustion  half  an  ounce  of  whisky,  with 
some  nourishment,  like  a  bowl  of  clear  soup  at  bedtime,  has 
produced  a  refreshing  sleep. 

IS'ext  to  the  bromides  in  procuring  rest  in  cases  of  neuras- 
thenia is  massage.  This  has  two  great  advantages.  The  first 
is  that  of  a  nerve  sedative,  and  its  passive  exercise  of  the 
muscular  system  and  stimulation  of  the  circulation  greatly 
improve  the  ultimate  nutrition.  It  does  in  the  way  of  exer- 
cise much  that  the  patient  in  health  can  do  for  herself.  The 
introduction  of  massage  in  rational  therapeutics,  as  an  aid  to 
ultimate  nutrition  and  a  nerve  sedative,  takes  very  high  rank. 
A  skillful  nurse  can,  by  systematic  manipulation,  soothe  the 
tegumentary  nerves,  and  produce  that  normal  effect  which 
invites  rest  and  sleep.  That  which  used  to  be  the  property  of 
designing  and  magnetic  rubbers  is  now  modified  and  adapted 
to  rational  use.  It  is  a  stone  which  the  builders  for  a  time 
rejected,  but  now  fills  an  important  corner.     This  massage  is 


NEURASTHENIA.  313 

true  passive  exercise — the  only  way  that  exercise  can  be 
given  without  exhausting  or  taxing  the  nerve  centers.  By 
this  means  the  muscular  system  can  be  quieted  down  to  the 
condition  adapted  to  normal  rest  and  sleep.  A  like  effect  ap- 
pears to  be  produced  upon  the  spinal  nerves. 

Finally,  there  are  many  cases  that  obtain  relief  from  all 
complications,  such  as  general  malnutrition  and  diseases  of 
the  sexual  organs,  and  still  the  neurasthenia  persists  ;  such 
patients  are  not  well,  although  they  appear  to  be,  and  they 
are  easily  exhausted,  mentally  and  physically. 

The  management  of  such  cases  is  very  briefly  well  summed 
up  at  the  close  of  a  very  valuable  essay  by  Dr.  Ludwig 
Bremer  in  the  Medical  Fortnightly,  February  15,  1894.  He 
states  as  follows  (I  have  taken  the  liberty  of  changing  the 
gender  of  the  patients  referred  to) : 

Briefly  stated,  the  treatment  of  neurasthenia  consists  in 
educating  the  patient  to  live  within  her  nerve-income,  which 
is  small.  The  woman  of  average  strength  can  not  with  im- 
punity attempt  to  perform  the  muscular  feats  of  an  athlete. 
Likewise  the  neurasthenic  can  not  do  what  many  of  her  ac- 
quaintances do  ;  she  is  to  forego  a  great  many  pleasures,  ab- 
stain from  many  pastimes  and  entertainments,  refrain  from 
many  articles  of  food,  which  to  her  seem  simple,  natural,  and 
healthy,  and  yet  stand  in  the  way  of  her  recovery.  She  must, 
above  all,  learn  her  limits.  Her  treatment  must  be  a  sort 
of  education,  teaching  her  the  difficult  art  to  adapt  herself 
to  her  surroundings,  to  re-establish  the  normal  equilibrium 
which  is  lost  between  her  as  an  individual,  and  her  environ- 
ments. To  mitigate,  if  not  prevent,  the  collapses  which  con- 
stitute such  a  discouraging  feature  in  the  course  and  progress 
of  neurasthenia — discouraging  to  the  patient  alike  and  the 
family — must  be  the  chief  object  of  treatment.  To  achieve 
this  end  the  patient  must  be  taught  to  avoid  extremes,  espe- 
cially of  emotion  and  work,  mental  or  physical ;  in  short,  a 
bodily  and  mental  hygiene  adapted  to  her  individuality  must 
be  instituted.  No  rest  cure,  no  seaside,  gymnastics,  cold  or 
warm  water — in  fact,  no  particular  method,  and,  least  of  all, 


314:  MEDICAL  GYNECOLOGY. 

drugs — will  bring  about  restoration  to  health.  They  may 
do  good  to  some  and  harm  to  others.  In  short,  there  is  no 
special  treatment  for  Beard's  disease,  but  there  are  many 
different  plans  of  treatment  for  different  'persons  suffering 
from  it.  In  other  words,  the  mdividual,  not  the  disease,  is 
to  be  treated. 


CHAPTER  XXyi. 

.  SEX  AISTD   ITS   RELATIONS   TO   INSANITY. 

The  interdependence  of  nervous  diseases  in  women  and 
their  sexual  organs  has  already  been  shown  in  some  slight 
degree  in  Chapters  XXIII  and  XXIV,  but  the  relations  be- 
tween the  various  forms  of  insanity  and  diseases  of  the  sexual 
organs  are  more  intimate,  more  generally  retroactive,  and  have 
had  but  little  investigation  from  the  medical  point  of  view. 
The  pathologist  can  not  undertake  this  study  successfully, 
for  he  is  not  a  gynecologist.  Nor  is  an  alienist  apt  to  ascribe 
to  physical,  demonstrable  causes  the  subtle  mental  changes 
we  call  insanity.  Moreover,  were  he  unprejudiced,  we  know 
that  derangements  of  the  mind  often  obscure  all  symptoms  of 
bodily  disease. 

Extended  facilities  for  studying  sex  and  its  relation  to  in- 
sanity presented  themselves  when  I  took  charge  of  the  gyne- 
cological practice  of  the  King's  County  Insane  Asylum  at 
Flatbush,  upon  invitation  of  Dr.  Shaw,  its  medical  director. 

In  beginning  the  study  of  the  four  hundred  patients  in 
that  institution,  the  first  thing  I  found  was  that  the  ordinary 
methods  of  investigation  were  of  little  or  no  value.  No  his- 
tories could  be  elicited  from  insane  women,  and  records  were, 
rightly  enough,  kept  with  reference  to  mental  conditions 
alone.  Nor  could  I  find  anywhere  a  system  of  examining  pa- 
tients and  recording  their  histories  from  the  point  of  view  of 
the  gynecologist.  Hence  I  devised  a  method  or  system  whose 
object  was  to  elucidate  the  relations  of  insanity  in  women  to 
the  condition  of  their  sexual  organs,  and,  on  the  other  hand,  the 
derangements  of  the  sexual  organs  dependent  upon  insanity. 

21  315 


316  MEDICAL  GYNECOLOGY. 

It  is  tempting  for  the  alienist  to  put  insanity  as  the  pri- 
mary, the  causative  event,  and  to  regard  any  pelvic  derange- 
ment as  an  accidental  accompaniment ;  and  we  know  that 
formerly  the  purely  medical  point  of  view  has  too  often  been 
that  insanity  is  a  late  result  of  disease  of  the  sexual  organs. 

The  obliteration  of  the  line  between  these  two  slightly 
antagonistic  domains,  the  unprejudiced  search  for  the  initial 
condition,  and  the  union  of  medical  and  jjsychological  means 
in  research  and  in  cure — these  were  the  objects  in  my  system 
of  investigation. 

Since  most  inquirers  have  chosen  the  sexual  organs  as  the 
starting  point  in  their  studies,  since  it  is  easier  to  begin  at  the 
tangible — the  demonstrable — in  working  up  to  the  functional, 
and  as  the  physician  has  the  advantage  of  knowing  when  his 
patients  have  uterine  or  ovarian  disease,  before  the  advent  of  ~ 
insanity,  we  are  not  surprised  that  a  more  correct  knowledge 
exists  concerning  the  effect  of  sexual  derangements  upon  in- 
sanity than  the  converse.  While  one  is  not  likely  to  overlook 
insanity  in  patients  known  to  have  disease  of  the  sexual  or- 
gans, the  psychologist  and  alienist  may  overlook  uterine  and 
ovarian  diseases  in  his  insane  patients. 

Enough  has  been  said  to  show  that  a  clear  distinction 
should  be  made,  in  the  study  of  aetiology,  between  insanity 
caused  by  existing  active  disease  of  the  sexual  organs,  and 
insanity  arising  from  brain  exhaustion,  produced  by  pro- 
longed or  excessive  functional  activity  of  these  organs  while 
free  from  any  disease.  I  incline  to  the  belief  that  as  many, 
or  even  more,  cases  of  insanity  can  be  traced  to  the  latter — 
i,  e.,  exhausting  activity — as  to  the  former — i.  e.,  active  dis- 
ease of  the  sexual  organs.  The  bearing  of  these  facts  upon 
the  diagnosis  and  treatment  of  insane  women  will  be  appar- 
ent to  all  medical  men.  In  the  one  class  of  cases  the  sexual 
organs  require  no  attention,  except  as  factors  in  the  indirect 
cause  of  the  mental  affection,  while  in  the  other  the  disease  of 
the  sexual  organs  is  the  direct  cause  of  insanity,  and  tends  to 
keep  it  up  until  removed  by  the  treatment  which  ought  in  all 
cases  to  be  instituted.     In  aU  that  follows,  in  all  that  is  said 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  317 

concerning  the  influence  of  tlie  sexual  organs  upon  insanity 
or  mental  derangement  of  any  sort,  I  wish  to  emphasize  the 
fact  that  an  underlying  taint,  usually  hereditary,  must  he 
present  or  latent ;  this  is  ever  to  be  understood. 

Following  the  plan  of  the  book,  insanity  at  puberty  first 
demands  attention  ;  and  while  it  is  true,  it  is  not  always  true, 
that  reflex  action  induces  insanity  at  the  outset  of  the  active 
period  of  life,  when  mental  derangement  appears  that  early. 
Mental  and  emotional  excitement,  along  with  the  demands 
of  the  reproductive  system  which  are  abruptly  made  at  that 
time  upon  the  nutritive  and  nervous  systems,  may  develop  in- 
sanity at  puberty  when  the  sexual  organs  are  well  developed 
and  perform  the  function  of  menstruation  normally. 

Perhaps  this  subject  can  be  more  clearly  elucidated  by 
giving  some  clinical  records. 

A  girl  fourteen  and  a  half  years  of  age,  belonging  to  an 
educated,  well-to-do  and  refined  family  wherein  there  was 
no  history  of  insanity  as  far  as  could  be  made  out,  passed 
through  all  the  physical  evolutions  of  puberty  normally,  but 
the  mental  characteristics  of  womanhood  were  exaggerated. 
The  girl  was  a  sensitif,  the  nervous  element  predominating  in 
her  temperament. 

At  puberty  her  modesty  became  marked  shyness,  her  lan- 
guor developed  into  indolence,  and  her  affections  assumed  the 
emotional  type.  She  complained  of  her  "head  feeling  queer," 
and  she  had  all  sorts  of  apprehensions  about  herself  and  her 
condition.  Backache,  general  malaise,  and  a  sense  of  full- 
ness and  engorgement  of  the  pelvis  were  all  magnified  in  her 
accounts  of  herself.  Now  she  was  moody  and  sought  to  be 
alone,  and  again  she  feared  solitude  and  hung  around  mother 
and  sisters,  complaining  of  feeling  badly.  At  times  she  was 
disposed  to  be  melancholy,  and  at  other  times  she  exhibited 
marked  irritability.  Occupations  that  once  were  pleasures 
became  annoying,  and  frequently  she  was  sleepless  and  had 
distressing  or  horrible  dreams.  All  these  symptoms  contin- 
ued until  her  mind  became  in  a  mild  way  unbalanced. 

I  asked  Dr.  J.  C.  Shaw  to  see  her  in  consultation,  and  he 


318  MEDICAL  GYNECOLOGY. 

pronounced  her  case  subacute  mania  due,  in  all  likelihood,  to 
puberty.  She  was  placed  in  the  care  of  a  nurse  thoroughly 
accustomed  to  the  charge  of  cases  of  mental  disorder,  and  her 
general  nutrition — which  was  faulty  as  shown  by  capricious 
appetite  and  constipation — was  improved  by  tonics  and  laxa- 
tives. Tepid  or  warm  baths  were  at  the  onset  employed  for 
their  sedative  action,  along  with  massage,  and  later  cold 
baths  were  used  for  their  tonic  effects. 

She  was  given  fifteen  grains  of  bromide  of  sodium  at  noon, 
evening,  and  bedtime,  along  with  three  drops  of  liquor  opii 
compositus.  She  was  secluded  from  association  with  her 
family,  especially  her  mother,  whose  sympathy  had  an  unfa- 
vorable effect  on  her. 

Under  this  treatment  she  readily  recovered,  and  then  for 
six  months  traveled  here  and  abroad.  She  is  now  married 
and  has  had  several  children,  and,  I  believe,  has  never  since 
shown  any  appreciable  weakness  of  mind  or  body. 

Another  case  which  contrasts  with  this  one  is  that  of  a 
girl  between  the  ages  of  fifteen  and  sixteen,  whose  father  and 
mother  were  both  healthy  German- Americans.  The  mother  was 
of  an  anxious,  care-taking  disposition,  who  sought  for  many 
things  to  worry  about,  and  who,  if  seeking  heaven  with  half 
the  energy,  would  at  once  be  crowned  with  glory.  This  mother 
informed  me  that  some  members  of  her  family  had  been  in- 
sane. Her  daughter  arrived  at  puberty  in  good  form,  health, 
and  strength,  with  a  record  of  previous  freedom  from  any 
important  illness.  She  passed  through  all  the  evolutions  of 
puberty,  assumed  all  the  womanly  characteristics,  entered 
into  social  and  educational  duties  with  renewed  vigor,  seemed 
to  enjoy  both,  and  was  just  as  ambitious  to  attract  the  oppo- 
site sex  as  her  girl  companions. 

She  soon  began  to  show  signs  of  overtaxation — the  appe- 
tite failed,  ansemia  appeared,  and  she  was  unable  to  keep  up 
with  school  and  society  duties.  All  this  caused  her  to  worry 
about  herself,  and  she  very  soon  surpassed  her  mother  in  fret- 
ting. Amenorrhoea  then  followed,  and  this  alarmed  both  her- 
self and  the  whole  household.    She  grew  extremely  apprehen- 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  319 

sive  concerning  herself,  not  only  fearing  that  she  might  become 
a  physical  wreck,  but  that  she  might  become  mentally  use- 
less. In  fact,  at  this  very  time  she  believed  herself  to  be  so, 
and  could  not  anticipate  any  amelioration  of  her  condition. 

This  brooding  over  her  imaginary  troubles  made  her 
withdraw  from,  even  shun,  all  companionship,  IN'ow  and 
again  her  mind  wandered,  and  she  finally  became  a  mono- 
maniac, her  mania  taking  on  the  form  wherein  she  "was  all 
wrong  "  and  "had  no  right  to  live  such  a  useless  life."  She 
avoided  every  one  save  the  members  of  her  own  family,  be- 
cause she  was  sure  every  one  was  laughing  and  jeering  at  her 
misfortune. 

During  this  time  I  treated  her  for  general  anaemia,  nervous 
exhaustion,  and  consequent  amenorrhoea,  joining  in  the  hope 
of  herself  and  mother  that  she  would  be  all  right  if  she  could 
only  menstruate.  The  mother  believed  that  the  menstrual 
derangement  was  the  whole  trouble ;  but  I  knew  that  her 
amenorrhoea  was  due  to  her  general  mental  and  physical 
state. 

She  improved  under  restorative  and  tonic  treatment,  and 
menstruated ;  but  her  mental  state  was  aggravated  rather 
than  improved  thereby.  She  was  then  placed  in  the  care  of 
Dr.  W.  Browning,  who  isolated  her  in  her  home  and  treated 
her  with  such  tonics  and  sedatives  as  were  indicated,  man- 
aging her  case  as  alienists  of  the  highest  order  do. 

This  resulted  in  recovery  in  ten  or  twelve  months  ;  in  fact, 
the  doctor  discharged  her  as  cured  at  the  time  of  this  writing, 
with  the  understanding  that  he  would  keep  her  under  obser- 
vation, feeling  that  there  was  a  possibility  of  a  relapse. 

The  greater  number  of  cases  of  insanity  occurring  at  pu- 
berty that  I  have  seen  were  in  those  with  a  marked  predis- 
position to  mental  alienation  and  in  whom  secondary  and  full 
development  of  the  sexual  organs  never  took  place.  Some 
of  these  cases,  I  find,  arrived  at  puberty  and  developed  in 
an  imperfect  degree  the  characteristics  of  the  mature  wom- 
an ;  menstruation  was  always  irregular  and  imperfect. 

Mentally  their  evolution  was  arrested,  and  in  place  of 


320  MEDICAL  GYNECOLOGY. 

becoming  womanly  and  intelligent  they  became  either  de- 
mented or  acutely  insane.  Upon  examination  of  these  under 
an  anaesthetic,  I  have  found  the  sexual  organs  all  present  but 
never  developed  to  a  normal  degree. 

In  another  class  of  cases  with  a  family  history  of  syphilis 
or  Insanity,  or  both,  they  were  mentally  weak — some,  it  is 
true,  were  physically  big  and  strong — and  at  a  little  past  the 
time  of  puberty  I  found,  in  place  of  secondary  development 
occurring,  that  such  girls  became  insane.  The  insanity  was 
at  times  acute,  at  times  a  partial  dementia  or  melancholia. 

It  is  during  the  active — the  child-bearing — period  of 
woman's  life  that  we  find  the  majority  of  cases  of  insanity, 
mania,  melancholia,  and  hallucinations  resulting  in  a  more  or 
less  direct  manner  from  diseases  and  derangements  of  the 
sexual  organs.  This,  of  course,  is  what  inductive  reasoning 
would  lead  us  to  expect,  for  between  the  times  of  puberty 
and  the  menopause  not  only  is  every  sexual  function  active, 
and  constantly  so,  but  the  relations  between  the  nervous  sys- 
tem and  the  pelvic  organs  are  closely  and  persistently  inti- 
mate. It  is  here  that  the  general  practitioner  and  worker 
along  the  usual  lines  of  practice  in  the  diseases  of  women  is 
reminded  how  little  he  has  done  with  the  opportunities  at  his 
command,  compared  with  the  even  scantier  researches  of  a 
similar  character  upon  the  part  of  the  psychologist  and 
alienist. 

How  diseases  of  the  sexual  organs  produce  insanity  is 
the  at  present  time,  and  in  many  cases,  a  mooted  question. 
Cause  and  effect  we  all  freely  admit,  but  the  mode  of  action 
of  this  cause  in  producing  this  effect  is  not  so  clear. 

Three  distinct  classes  of  cases  can  be  determined  where,  at 
the  active  period  of  life,  sexual  derangement  produces  in- 
sanity, irrespective  of  reflex  action  : 

Firstly,  among  young  widows  there  is  a  social  famine,  a 
disaster  to  the  nervous  system,  that  results  from  an  abrupt 
change  in  the  active  period  of  life.  A  woman  has  been  hap- 
pily performing  all  the  functions  of  that  period,  and  the 
deprivation  induces  emotional  disturbances  that  are  largely 


SEX  AND  ITS  KBLATIONS  TO   INSANITY.  321 

potential  in  unbalancing  the  mind  ;  hence  melancholia  or  in- 
sanity follows. 

Secondly,  sterile  married  women,  who  want  children  and 
are  made  doubly  unhappy  by  living  in  hope  and  longing, 
often  become  insane,  for  their  emotions  are  perverted,  so 
that  home  life  is  miserable,  and  they  have  the  mortification 
of  knowing  their  inability  to  procreate,  or  else  are  suspicious 
that  the  failure  is  due  to  the  husband.  This,  of  course, 
wrecks  the  social  system,  and  is  in  itself  enough  to  unbal- 
ance a  mind  not  originally  strong,  or  entirely  free  from  any 
hereditary  taint  of  insanity. 

Thirdly,  a  class  that  may  eventuate  in  insanity  is  that  in 
which  oftentimes  there  has  been  a  long  engagement — as  it  is 
called — not  ending  with  a  marriage,  especially  where  privi- 
leges have  been  indulged  in  for  which  no  legal  right  as  yet 
existed. 

Lastly,  we  arrive  at  the  most  difficult  subject  to  discuss — 
sexual  perversion,  which  is  meant  to  include  all  kinds  of  self- 
abuse.  This  subject  I  have  already  treated  of  in  a  preceding 
chapter.  It  is  referred  to  thus  briefly  here,  since  it  is  taken 
for  granted  that  the  various  means  of  self -gratification  are 
well  understood. 

There  is  a  condition — as  yet  undescribed,  so  far  as  I  know 
— that  I  shall  venture  to  call  "  mental  masturbation."  Occur- 
ring in  both  sexes,  it  is  much  more  frequent  in  young  women 
than  in  men,  at  any  age. 

The  results  of  mental  masturbation  are  akin  to  or  identi- 
cal with  those  of  the  more  loathsome  practice ;  and  I  have 
witnessed  them  chiefly  among  the  physically  strong,  non- 
studious  society  girl  of  the  upper  classes.  She  bathes,  has 
massage,  pays  every  attention  to  her  person — none  at  all  to 
her  mind — lives  a  life  amid  erotic  surroundings,  is  stimulated 
by  lights,  music,  the  dance,  the  supper,  the  wines,  and  next 
day  is  enervated.  At  the  end  of  a  season,  wherein  her  nervous 
system  has  been  on  a  tension,  her  senses  all  aroused,  and  her 
higher  faculties  kept  in  abeyance,  and,  too,  after  she  has  had 
men  for  her  almost  constant  attendants  and  companions,  how 


322  MEDICAL  GYNECOLOGY. 

can  we  be  surprised  if  nervous  exhaustion  with  leucorrhcea 
and  mental  and  menstrual  derangements  are  prominent 
symptoms  ? 

In  a  sensitif  I  have  no  doubt  that  a  displacement  or  an 
acute  disease,  either  of  the  uterus  or  the  ovary,  is  quite  suffi- 
cient to  cause  a  mental  derangement  which  may  or  may  not 
subside  upon  cessation  of  the  pelvic  disease.  While  such 
clearly  reflex  cases  are  not  uncommon,  we  observe  a  great 
many  more  wherein  reflex  action  plays  no  part,  and  where 
with  great  certainty  the  physical  pelvic  causes  are  alone  to  be 
held  responsible. 

I  have  seen  patients,  suffering  from  uterine  disease  exist- 
ing for  many  years,  finally  becoming  insane  or  melancholy 
without  the  slightest  exacerbation  of  the  organic  malady; 
and  it  seems  most  probable  that,  from  the  prolonged  suffer- 
ing, perhaps  depletion,  the  nutrition  of  the  brain  became  im- 
paired or  altered  at  first,  so  that  the  reflex  action  did  not  enter 
as  a  causative  factor.  Here  the  direct  cause  is  a  lesion  of  nu- 
trition of  the  brain — ^perhaps  demonstrable  to  the  pathologist 
— produced  ultimately  by  irritation  and  exhaustion  from 
uterine  or  ovarian  disease. 

We  find  the  same  organic  disease  of  the  uterus  and  ovaries 
in  insane  women  as  in  their  rational  sisters,  with  identical 
physical  signs,  but  a  marked  difference  in  or  absence  of  sub- 
jective symptoms.  Malignant  uterine  disease  occurs,  I  think, 
a  little  more  frequently  in  insane  than  sane  women  ;  and  I 
believe  that  sequelae  of  previous  diseases — as  pelvic  peritoni- 
tis, pelvic  cellulitis,  puerperal  metritis,  and  the  like — are 
found  more  frequently  in  this  class  of  cases. 

Menstrual  derangements,  dysmenorrhoea  pre-eminently, 
and  at  times  the  normal  event  itself,  cause  or  are  accompanied 
by  a  more  or  less  mild  form  of  alienation,  which,  from  its 
regularity  of  occurrence  at  stated  intervals,  is  called  periodic 
insanity. 

Here,  as  in  all  other  cases,  there  is  either  a  hysterical  per- 
sonality or  a  predisposition  to  insanity.  This  is  particularly 
noticeable  in  cases  of  temporary  aberration,  occurring  during 


SEX  AND   ITS  RELATIONS   TO  INSANITY.  323 

a  normal  menstruation.  When  there  is  dysmenorrhoea,  due 
to  some  lesion  of  the  sexual  organs,  the  suffering  is  sufficient 
to  unbalance  a  defective  brain  and  nervous  system. 

Among  women  of  the  poorer  classes  frequent  child-bearing 
and  lactation  stand  among  the  most  noteworthy  and  impor- 
tant causes  of  insanity.  My  own  clinical  observation,  a  pe- 
rusal of  the  records  of  all  the  asylums  in  this  country,  and 
the  testimony  of  observing  medical  men — all  these  prove 
that  the  great  drain  imposed  upon  women  by  too  frequent 
maternal  duties  deranges  the  mind  of  the  majority  of  them 
to  some  extent. 

It  has  already  been  said  that  the  largest  number  of  insane 
women  are  found  in  the  active  period  of  life — to  be  exact,  be- 
tween the  twenty-fifth  and  fortieth  year  of  life — and  of  these 
a  very  large  percentage  have  been  married  and  have  borne 
children.  To  be  sure,  some  of  these  may  have  had  coexistent 
disease  of  the  sexual  organs,  but  the  exhaustion  of  lactation 
and  of  frequent  child-bearing,  without  any  other  complica- 
tions, sufficed  to  bring  on  more  or  less  mental  derangement. 

Extraordinary  functional  activity  of  one  set  of  organs  has 
here  so  detracted  from  the  normal  performance  of  another,  an 
intimate  associate,  that  the  brain  has  suffered  at  the  expense 
of  the  sexual  system.  Were  the  histories  and  records  in 
asylums  kept  with  some  view  of  the  interdependence  of  the 
pelvic  organs  and  nervous  system,  I  have  not  the  slightest 
doubt  but  that  statistical  evidence  would  be  overwhelming  in 
proving  the  above  statements. 

Since  mental  weakness,  nervous  exhaustion,  or  nervous 
depression  is  the  very  first  manifestation  of  disease,  since  no 
palpable  pelvic  condition  is  present  to  attract  the  physician's 
attention  when  the  cause  of  mania  is  being  sought  for  in  those 
who  are  exhausted  and  worn  out  from  child-bearing  and 
nursing,  we  can  readily  account  for  the  paucity  of  our  medi- 
cal literature  on  this  subject.  There  is  no  dearth  of  explana- 
tion when  it  is  a  question  of  anaemia  from  lactation,  but  sub- 
sequent nervous  conditions  are  untouched — uninvestigated, 
perhaps  unsought  for. 


324  MEDICAL  GYNECOLOaY. 

And  liow  is  it  that  the  exercise  of  the  normal  function  of 
womanhood  should  so  often  unbalance  not  only  the  physical 
but  the  mental  equilibrium  ?  Outside  the  effects  of  rapid  and 
long-continued  reproduction  we  find  the  answer  is,  that  too 
many  physical  and  mental  cares  of  all  sorts  and  conditions 
overwhelm  women  during  the  reproductive  period.  How 
often  do  we  see  among  the  poor  that  they  have  to  work 
steadily  for  very  existence  while  attending  to  household 
duties — "after  hours,"  as  it  were — and  then  in  addition  bear 
children  and  give  them  sustenance  ?  Among  the  rich  a  simi- 
lar state  of  affairs  exists,  except  that  here  the  manifold 
duties,  onerous  and  irksome  even  if  social,  are  self-imposed, 
and  perhaps  more  mental  than  physical,  and  to  my  mind,  for 
this  reason,  worse,  from  the  point  of  view  of  future  mental 
health  when  maternal  duties  are  carried  out. 

ISTo  constitution  can  endure  the  dual  task  of  labor  and  ma- 
ternity, with  its  drains  on  mind  and  body,  without  weakening 
perceptibly  and  finally  breaking — the  break  all  too  often  be- 
ing shown  by  mental  derangements.  What  the  female  or- 
ganization has  to  undergo  in  destructive  metamorphosis  and 
waste  without  compensatory  repair  I  question  if  physicians 
fully  appreciate  or  estimate. 

Often  during  pregnancy  personal  nutrition  seems  to  in- 
crease, perhaps  indeed  it  is  more  than  an  appearance  of  well- 
being,  and  the  evidence  of  good  health  is  trustworthy.  There 
are  also,  at  this  time,  an  ability  and  readiness  to  do  work  that 
is  astonishing.  Yet  should  this  potential  energy  be  abused, 
general  debility  must  follow.  Women  very  frequently  resist 
this  added  tax,  and  keep  on  using  their  powers  energetically, 
so  that  no  ill  effects  are  apparent  at  the  onset.  This  is  espe- 
cially the  case  at  the  first  pregnancy  and  lactation,  after 
which  "the  best  health  of  their  lives"  may  be  claimed ;  but 
the  rei)etition  of  these,  with  the  resiDonsibilities  that  accrue 
with  each  advancing  year  and  child,  induce  nervous  oppres- 
sion, nervous  exhaustion,  and  mental  derangements  at 
the  last. 

This  course  of  events  I  have  noticed  especially  among  the 


SEX  AND  ITS   RELATIONS  TO   INSANITY.  325 

class  of  women  who  have  been  raised  in  ease  and  comfort 
without  having  acquired  habits  of  industry  or  regularity.  It 
is  when  daughters  of  this  class  marry  and  live  in  less  affluent 
circumstances,  or  when  an  adverse  tide  of  affairs  sets  in,  priva- 
tion and  fretful  disappointment  being  constant  attendants  of 
household  duties  and  cares,  that  the  "raising  of  a  family" 
has  in  it  all  the  factors  necessary  for  inducing  insanity. 
Among  asylum  records  many  such  histories  can  be  elicited. 
This  insanity  is  not  reflex ;  it  is  generally  centric,  although 
indirectly  dependent  on  the  sexual  organs. 

Many  facts  might  be  adduced  to  prove  that  the  normal 
functional  activity  of  the  sexual  organs  tends  to  undermine 
the  brain  and  nervous  system  to  an  extent  quite  sufficient  to 
lead  to  insanity  if  carried  to  extremes  and  under  unfavorable 
conditions.  IN'ot  only  do  certain  organic  diseases  of  the  sex- 
ual organs  play  a  most  important  part  in  causing  insanity, 
but  they  tend  to  retard  restoration  of  the  normal  mental 
equilibrium.  All  diseases  of  the  uterus,  vagina,  and  ovaries, 
where  there  is  alteration  in  structure  or  change  in  position, 
are  strong  setiological  factors.  Moreover,  conditions  that  are 
products  of  diseases  or  sequelae  of  them— as  pelvic  peritonitis, 
pelvic  cellulitis,  and  cicatrices  of  the  cervix  or  vagina— of  ten 
induce  severe  enough  pelvic  pains,  through  pressure,  adhesion, 
or  contraction,  to  cause  or  aid  in  the  continuance  of  insanity. 

Unfortunately,  unlike  functional  diseases,  these  affections 
of  the  sexual  organs  are  not  relieved  upon  the  occurrence  of 
mental  derangement.  A  lacerated  cervix,  or  a  displacement 
of  the  uterus  or  ovaries,  could  not,  of  course,  be  restored  to 
normal  by  any  mental  derangement  that  ensued.  Indeed,  on 
the  contrary,  insanity  is  often  a  bar  to  necessary  treatment, 
and  so  sexual  derangements  and  insanity  aggravate  each 
other  reciprocally  and  recovery  of  either  is  retarded. 

It  is  certain  that  when  diseases  of  the  generative  organs 
exist  in  insane  women  the  brain  condition,  if  at  all  influ- 
enced, is  influenced  for  the  worse.  And  we  can  not  but 
believe  that  if  certain  diseases  of  the  sexual  organs  are  capa- 
ble of  causing  insanity,  they  must  also  tend  to  its  continu- 


326  MEDICAL  GYNECOLOGY. 

ance.  It  is  to  tins  class  of  genital  affections  among  the  insane 
that  the  science  and  art  of  gynecology  ai3ply  with  marked 
advantage. 

To  be  sure,  general  anaesthesia  that  appears  in  some  forms 
of  insanity  may  relieve  the  patient  from  pain  and  suffering 
induced  by  old  adhesions. 

In  chronic  ovaritis  and  in  prolapse  of  the  ovaries  the  pain 
may  be  diminished  as  much  by  the  mental  alienation  as  by 
opium.  We  are  not  sure,  however,  but  that  the  disease  of 
the  sexual  organs  may  still  be  exerting  its  baneful  influence 
on  the  general  and  nervous  systems.  If  insane  fancies  engage 
steadily  the  patient's  attention,  the  local  incubation  may 
nevertheless  play  as  sad  havoc. 

Insanity  at  the  menopause  is  often  traced  to  general  sys- 
temic derangement  or  imperfect  elimination,  rather  than  to 
disease  of  the  sexual  organs.  The  older  authors  were  wont  to 
ascribe  it  to  sudden  suppression  of  a  habitual  discharge.  On 
referring  to  the  chapter  on  menstruation  and  its  derange- 
ments it  will  be  found  that  in  one  class  of  cases  the  meno- 
pause is  attended  or  followed  by  a  decided  activity  of  nutri- 
tion with  an  indisposition  to  mental  or  physical  exertion.  As 
a  result  we  have  imperfect  assimilation,  faulty  elimination, 
and,  as  a  consequence  of  these,  excrementitious  plethora. 
The  effect  upon  the  brain  of  all  this  is  to  produce  a  certain 
degree  of  torpor  and  melancholia,  and  insanity  is  almost  cer- 
tain to  be  developed  if  there  exists  what  is  now  called  the 
psychotic  state. 

An  entirely  opposite  condition  is  seen  in  those  who  at  the 
menopause  suffer  from  malnutrition,  and  have  increased  men- 
tal excitement  and  ability  with  lessened  power.  Such  women 
usually  have  dyspepsia,  lose  flesh,  become  sleepless,  and  fret 
or  worry  on  every  possible  opportunity.  Their  brain  partakes, 
of  course,  of  the  general  malnutrition,  and,  if  this  is  permitted 
to  go  on,  some  form  of  insanity  is  almost  certain  to  ensue. 

There  is  yet  another  class— and  perhaps  the  most  numer- 
ous— who,  possessing  vigorous  health  and  enjoying  all  the 
luxuries  of  life,  have  so  assiduously  cultivated  the  habits  of 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  S27 

sexual  intercoarse  that,  instead  of  a  diminution  of  the  sexual 
appetite  at  the  menopause — as  normally  is  the  case — it  re- 
mains as  in  the  active  period  of  life.  When  menstruation 
finally  ceases,  the  subject  obtains  no  longer  the  relief  from  the 
sedation  of  a  free  flow,  and  appetence  is  therefore  increased. 
Unfortunately,  there  is  sometimes  in  such  cases  an  inability 
to  obtain  relief  from  complete  gratification.  This  is  a  mental 
condition  which  does  not  always  receive  physical  compensa- 
tion, owing  to  the  impossibility  of  fully  performing  the  func- 
tion. This  is  a  quite  suflBcient  cause  for  erotomania,  the  form 
of  insanity  usually  but  not  always  developed  in  these  cases. 

To  instance  a  few  typical  cases  :  A  lady  of  excellent  con- 
stitution and  good  health,  the  mother  of  a  number  of  chil- 
dren, and  who  was  of  a  decidedly  lymphatico-nervous  tem- 
perament— a  sensitif-apatMque,  which  Ribot  says  is  an  ex- 
tremely rare  but  possible  temperamental  union — approached 
the  menopause  with  excellent  health,  good  digestion,  and  in 
the  full  enjoyment  of  life  in  all  its  relations. 

When,  finally,  menstruation  ceased  she  gained  a  little  in 
flesh,  became  florid,  was  sometimes  drowsy  and  apathetic  in 
the  daytime,  and  restless  during  the  night,  with  broken  sleep 
and  disagreeable  dreams.  She  complained  of  headache  ;  had 
"queer"  feelings  ;  became  disinterested  in  her  family  and  in 
affairs  generally  ;  talked  about  herself  continually  ;  and  had 
all  sorts  of  strange  ideas,  which  at  first  she  was  aware  were 
foolish.  Acute  indigestion,  constij)ation,  haemorrhoids,  and 
scanty,  muddy  urine  were  symptoms  next  noted.  Then,  in 
the  hope  of  distracting  her  attention,  she  traveled  abroad  and 
fell  into  the  hands  of  a  physician  in  Spain,  who,  mistaking 
her  mental  state  for  one  due  to  debility,  increased  the  quan- 
tity of  wine  at  her  dinner  and  gave  morphine  suppositories  for 
the  haemorrhoids,  which  latter  were  the  only  physical  discom- 
fort of  the  patient.  Unfortunately,  she  was  made  more  com- 
fortable by  this  treatment,  and  soon  became  dependent  on  the 
suppositories,  returning  from  abroad  in  six  or  eight  months 
much  worse. 

When  I  saw  her  I  made  a  diagnosis  of  subacute  mania, 


328  MEDICAL  GYNECOLOGY. 

and  placed  her  in  the  hands  of  Dr.  Shaw,  who  isolated  her 
in  her  house  and  placed  her  in  charge  of  a  very  competent 
nurse.  He  very  gradually  diminished  the  quantity  of  opium 
and  stimulated  her  elimination  by  toning  up  the  liver  and 
kidneys  and  exciting  the  skin  and  bowels  to  perform  their 
functions.  I  believe  he  also  gave  her  nerve  tonics,  nux  vomica 
in  full  doses.  She  gradually  recovered,  and  for  the  past 
three  years  has  been  perfectly  well. 

A  very  different  type  is  that  where  malnutrition  is  the 
chief  factor.  At  my  clinic  in  the  hospital  I  saw  an  Ameri- 
can woman  of  nervous  temperament,  who  had  no  taint  of  in- 
sanity or  predisposition  thereto  so  far  as  I  could  find  out. 
She  was  of  an  extremely  active  disposition — frugal,  industri- 
ous, and  ambitious. 

She  had  long  neglected  her  diet ;  and  although  in  her 
usual  health  at  the  menopause,  her  appetite  then  became 
capricious,  and  she  grew  inattentive  to  her  eating.  The  meno- 
pause came  in  the  usual  way,  but  her  malnutrition  increased, 
and  what  was  formerly  her  mental  and  moral  activity  now 
became  excitability.  She  was  impatient,  slept  but  little  and 
that  restlessly,  had  headaches,  backaches,  and  some  pelvic 
tenesmus,  though  without  the  slightest  evidence  of  any  dis- 
ease of  the  sexual  organs.  All  this  account  was  elicited  from 
her  at  her  first  appearance  at  my  clinic. 

Rest,  nutritive  food,  and  tonics  were  ordered,  and  seda- 
tives, camphor,  hyoscyamus,  and  lupulin  were  given  at  bed- 
time, l^o  improvement  followed,  due,  I  fear,  to  the  fact  that 
the  treatment  was  not  carried  out,  especially  as  concerned  rest 
and  diet,  which  I  considered  the  most  important  factors. 
Becoming  worse,  she  was  sent  to  the  asylum,  and  I  regret  to 
say  I  did  not  get  her  subsequent  history.  She  certainly  had 
acute  mania  when  last  seen  by  me. 

Recently  I  have  seen  two  cases,  which  seem  quite  typical, 
where  increased  sexual  appetence  following  the  menopause 
led  to  insanity. 

The  first  of  these  cases  was  that  of  a  lady,  in  excellent 
health  and  condition,  married  to  a  man  vigorous  mentally 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  329 

and  physically,  wlio  had  an  abundance  of  means,  a  good 
social  and  public  business  position,  and  who  lived  very  gen- 
erously. They  were  equally  fond  of  society,  champagne,  and 
sexual  indulgence.  The  husband  died  when  she  was  near 
the  menopause  ;  she  felt  the  loss  keenly  and  for  a  long  time 
was  very  emotional.  In  addition,  she  had  backache  and 
leucorrhcea,  with  abnormal  irritation  of  the  sexual  organs. 
She  hoped  all  this  would  subside  after  the  menopause,  but 
herein  sh§  was  disappointed,  for  her  sexual  desires  greatly 
increased.  She  slept  poorly,  and  almost  every  other  night 
had  "a  dream  that  was  not  all  a  dream."  She  suffered  more 
yet  from  backache,  vesical  and  general  pelvic  tenesmus,  and 
a  feeling  of  weakness,  due  more  to  oppression  than  to 
exhaustion.  Her  physician  gave  her  tonics  and  an  abun- 
dance of  nutritious  food  with  her  wine  at  dinner — to  which 
last  she  was  long  accustomed — and  even  advised  more  stimu- 
lants ;  this  produced  indigestion  and  brought  about  rheu- 
matic pains  which  crippled  her  by  specially  involving  the 
knees. 

She  sought  relief  by  frequenting  society,  but  here  she  was 
unfortunate  enough  to  become  enamored  of  a  man  much  her 
senior,  who  had  known  her  in  her  palmy  days,  and  who,  as 
far  as  possible,  reciprocated  her  affection.  They  were  unable 
to  see  each  other  save  at  long  intervals,  and  then  only  in 
society.  This  very  much  aggravated  the  condition  of  affairs, 
and  she  spent  much  of  her  time  weeping  over  the  loss  of  her 
husband  and  in  regretting  that  she  could  not  enjoy  the  soci- 
ety of  her  new  object  of  attraction. 

When  she  came  under  my  observation  I  found  a  mild  at- 
tack of  senile  vaginitis,  vulvitis,  and  metritis  ;  her  tongue  was 
heavily  coated  ;  secretion  and  excretion  were  sluggish  and 
embarrassed ;  and  the  urine  was  loaded  with  solid  constitu- 
ents, keeping  up  a  cystic  irritation  which  caused  her  to  uri- 
nate frequently  during  the  day  and  occasionally  at  night. 
The  deranged  innervation  of  the  bladder  was  such  that  when 
a  desire  to  micturate  came  and  she  was  unable  to  promptly 
relieve  herself,  there  was  some  incontinence.    I  endeavored  to 


330  MEDICAL  GYNECOLOGY. 

correct  her  digestive  disturbance  by  putting  her  on  a  spare 
diet,  sto|)ping  all  stimulants,  and  giving  her  lithia  water  to 
drink,  with  pepsin  and  diastase  after  her  meager  meals,  to  in- 
sure their  complete  digestion.  To  aid  in  obtaining  sleep  I 
administered  bromide  of  sodium  afternoons  and  evenings  with 
small  doses  of  nux  vomica. 

Baths  and  massage  were  employed  to  relieve  the  rheuma- 
tism, the  massage  being  followed  by  light  gymnastic  exercise 
and  riding  in  the  open  air.  She  imjDroved  a  little,  but  the 
gain  was  not  lasting,  and  gradually  she  acquired  subacute 
mania  of  the  erotic  character.  Now  she  is  a  half-demented 
creature,  who  spends  her  time  weeping  over  the  ecstasies  of 
her  j)ast  life,  and  longing  for  aid  and  relief. 

The  influence  of  diseases  and  abnormal  conditions  of  the 
sexual  system  in  producing  some  form  of  insanity  is  felt  not 
only  at  puberty,  in  the  active  period  of  woman's  life,  and  about 
the  time  of  the  menopause,  but  after  the  "change  of  life" 
is  well  over — in  what  we  may  call  the  senile  part  of  life — we 
find  the  potent  factor  still  at  work.  To  instance  one  typical 
case :  At  the  request  of  Dr.  Shaw  I  have  recently  seen  a 
widow,  childless,  about  sixty  years  of  age,  who  was  wealthy, 
and  insisted  on  living  in  her  elegant  house  alone  with  her 
servants  and  a  young  lady  attendant,  spending  most  of  her 
time  in  bed.  She  was  very  emotional,  and  suspicious  of  all 
her  friends  and  relatives,  fearing  that  they  much  desired  her 
money  and  property.  She  had  long  been  thought  "queer," 
and  for  about  a  year  before  I  saw  her  had  been  in  some  sani- 
tarium for  nervous  diseases. 

I  believe  Dr.  Shaw  considered  her  half  insane,  and,  al- 
though reticent,  she  had  told  him  of  pain  and  distress  about 
the  pelvic  region,  and  he  suspected  she  must  have  some  dis- 
ease of  the  sexual  organs.  I  gained  her  confidence  so  that 
she  admitted  that  at  night  in  her  sleep  she  "had  dreams" 
("as  if  her  husband  visited  her").  She  complained  of  an 
acute  pain  in  the  neighborhood  of  the  clitoris,  greatly  aggra- 
vated by  standing  or  walking.  On  an  examination,  I  found 
no  disease  of  the  sexual  organs,  save  that  the  clitoris  was  un- 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  331 

usually  large  ;  and  I  was  unable  to  find  out  whether  the  pain 
arose  from  neuralgia  of  the  pudic  nerve  or  from  an  engorge- 
ment of  the  erectile  tissue  of  the  clitoris  and  parts  about  it. 
I  presume  it  was  the  latter,  on  account  of  its  exacerbation  on 
standing.  I  reported  her  condition  to  Dr.  Shaw,  but  I  under- 
stand she  declined  treatment  directed  toward  her  sexual  or- 
gans, and  I  learn  that  she  has  not  improved.  What  the  out- 
come will  be  I  know  not. 

It  now  ^remains  to  study  the  effect  of  insanity  upon  the 
function  of  the  reproductive  system,  and  here  it  should  be 
said  that  the  time  of  life  at  which  I  studied  insanity  was,  per- 
force, the  middle  period,  two  hundred  cases  being  between 
the  ages  of  seventeen  and  forty-six.  For  six  months  these 
women  were  carefully  watched  from  the  point  of  view  now 
under  discussion,  and  at  the  end  of  that  time  but  eight 
were  lost,  from  death  or  having  been  discharged  from  the 
asylum.  ^ 

Menstruation  was,  of  course,  that  function  whose  derange- 
ments could  be  most  readily  watched  and  discovered,  and  it 
was  to  abnormities  in  this  important  function  that  I  first 
directed  my  investigations.  Of  the  remaining  192  women, 
only  27  menstruated  regularly  and  normally,  30  did  not  men- 
struate at  all,  4  menstruated  once,  8  twice,  10  three  times,  18 
four  times,  34  five  times,  24  six  times  at  irregular  intervals,  31 
seven  times,  and  6  eight  times  during  the  six  months.  It  is 
thus  seen  how  the  menstrual  function  is  affected  by  insan- 
ity ;  and  I  think  there  are  few  other  conditions  where  such  a 
marked  disturbance  is  a  result. 

One  of  two  causes  may  be  at  work  here  :  First,  the  im- 
paired general  nutrition  that  we  so  often  find  in  insane  pa- 
tients. All  functional  activity  not  absolutely  necessary  to  life 
is  suspended  in  these  cases,  since  general  health  is  reduced 
to  such  a  low  standard.  This  is  the  same  state  of  affairs  as  we 
find  in  all  severe  exhausting  diseases,  notably  phthisis  pul- 
monalis.  It  is  really  a  conservation  of  energy.  ISTature  sus- 
pends certain  functions  whose  absence  will  not  too  seriously 

damage  the  feeble  organization,  and  we  regard  this  as  a  for- 

22 


332  MEDICAL  GYNECOLOGY. 

tunate  provision.  Malnutrition  sums  up  tlie  cause  of  amenor- 
rhoea  in  tMs,  the  first  class  of  cases.  Here  the  sexual  organs 
were  generally  found  ansemic,  having  all  the  appearances  of 
those  in  women  who  have  passed  the  menoxDause,  save  that  the 
atrophy  found  in  the  very  aged  was  not  present. 

A  careful  investigation  of  those  cases  wherein  the  menses 
were  suppressed  revealed  the  fact  that  in  the  majority  im- 
paired nutrition  of  the  sexual  organs  was  the  basis  of  the 
amenorrhoea. 

Secondly,  the  diseased  or  abnormal  nervous  system  can 
be  the  sole  cause  of  the  menstrual  abnormity.  There  were 
a  few  cases  in  the  above  list  where  general  nutrition  was 
good — normal — and  the  pelvic  organs  were  in  a  healthy  con- 
dition, yet  where  there  was  decided  amenorrhoea.  Faulty 
innervation  was  here  the  certain  cause,  and  an  abundance  of 
proof  might  be  adduced  to  show  how  suspension  of  the  func- 
tions—one or  all — of  the  sexual  organs  arises  in  the  insane 
from  deranged  innervation.  We  are  all  familiar  with  cases 
of  acute  suppression  of  the  menses  arising  from  mental 
shocks,  prolonged  mental  anxiety,  and  the  like  ;  and  these 
afford  proof  of  our  belief  that  deranged  innervation  can  be 
and  often  is  a  sole  cause  for  amenorrhoea  in  the  insane. 

The  rule  thus  seems  to  be  that  insanity  induces  amenor- 
rhoea, and  as  some  of  the  patients  who  were  in  my  care  men- 
struated regularly,  or  had  menorrhagia  or  too  frequent  men- 
struation, the  reason  for  this  had  naturally  to  be  sought  for. 

I  found  menstruation  to  be  affected  in  proportion  to  the 
degree  of  the  insanity.  In  women  who  menstruated  regularly, 
the  insanity  was  of  so  mild  type  that  neither  nutrition  nor  in- 
nervation was  deranged,  while  in  those  who  had  menorrhagia 
or  who  menstruated  too  frequently  there  was  some  form  of 
uterine  disease.  These  latter  symptoms  point  to  uterine  dis- 
ease, and  should  be  accepted  as  evidence  of  it  in  insane  women. 

It  is,  however,  by  no  means  claimed  that  amenorrhoea  is  a 
certain  indication  that  all  the  functions  of  the  sexual  organs 
are  in  abeyance.  Not  only  may  ovulation  go  on  as  usual,  but 
the  sexual  appetence  may  exist  in  its  normal  degree,  as  we  all 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  333 

know,  when  menstruation  is  absent.  This,  it  must  be  said,  is 
rather  the  exception  than  the  rule. 

N'evertheless,  there  are  still  other  reasons  for  the  belief 
that  a  general  functional  inactivity  prevails  in  insane  women 
who  have  amenorrhoea ;  for  in  a  few  cases  of  this  class  who 
have  died,  and  on  whom  a  post-mortem  examination  could 
be  made,  I  found  no  evidence  of  ovulation  having  occurred. 
Ovulation  is  thus  seen  to  be  arrested  in  insanity,  in  some  few 
cases  at  least ;  but  more  evidence  is  needed  to  fully  establish 
this  statement  in  a  general  way.  Another  evidence,  to  me, 
that  the  sexual  organs  return  for  a  time  to  a  condition  border- 
ing on  the  functional  inactivity  of  childhood  or  advanced  age 
is  the  fact  that  insane  women  rarely  if  ever  manifest  maternal 
or  marital  affection  of  any  kind  ;  and  we  know  these  to  be 
ruling  passions  in  woman' s  life  ordinarily. 

One  question  in  this  connection  seems  to  demand  special 
attention — both  from  its  interest  medically  and  because  so 
little  has  ever  been  said  or  known  regarding  it — and  that 
is,  What  effect  does  insanity  have  upon  diseases  of  the  sexual 
organs  ? 

First  in  importance  comes  that  class  of  maladies  where 
the  functional  activity  of  the  sexual  organs  is  deranged  from 
abnormal  innervation  or  alterations  in  the  vascular  supply  ; 
where  the  organs,  anatomically,  are  normal,  and  to  whose 
morbid  state  the  term  "functional  disease  " is  so  aptly  applied 
elsewhere  in  this  work. 

I  find  most  authorities  on  uterine  pathology  admit  that 
very  many  diseases  of  the  sexual  organs  met  with  in  practice 
result  from  hypersemia — active  or  passive — and  changes  in 
nerve  irritability,  where  alterations  in  the  caliber  of  the  ves- 
sels and  changes  in  quantity  and  even  quality  of  blood  are 
prominent  but  temporary  conditions.  The  vessels  are  al- 
ways ready  to  regain  their  normal  tonicity,  and  capable  of 
doing  so.  Here  the  influence  of  insanity  is  most  favorable. 
Functional  uterine  diseases  may  be  said  to  vanish  on  the  oc- 
currence of  mental  alienation.  The  statement  that  "insanity 
cures  functional  maladies  of  the  sexual  organs  "  can  not  be 


334  MEDICAL  GYNECOLOGY. 

questioned,  the  proof  being  based  on  thorough  clinical  inves- 
tigation. It  should  not  be  forgotten  that  functional  dis- 
orders alone  are  referred  to.  Of  course  there  are  exceptions  ; 
and  those  who  have  masturbated  or  have  suffered  a  mental 
derangement  of  a  venereal  kind,  while  free  from  uterine  or 
ovarian  disease,  have  centric  affections  only,  and  belong  to 
quite  another  class. 

This  disappearance  of  functional  disorders  on  the  super- 
vention of  insanity  agrees  with  what  has  been  said  about 
the  effects  of  mental  alienation  on  the  generative  functions. 
If  the  vitality  of  one  system  may  be  lowered  by  disease  else- 
where to  an  extent  that  its  function  is  annihilated,  it  is,  per- 
force, reasonable  to  expect  return  of  function  when  the  current 
is,  as  it  were,  turned  on.  Pathologically,  also,  it  is  true  that 
disease  in  one  part  of  the  body  may  disappear  when  some 
morbid  activity  is  set  up  in  another.  This  has  long  been 
called  "  antagonism  of  diseases." 

I  watched  the  progress  of  a  case  to  illustrate  the  principle 
just  enunciated.  The  woman  had  congestion  of  the  uterus 
and  leucorrhoea,  and  when  she  became  insane  both  these  con- 
ditions vanished  and  that,  too,  without  local  treatment.  Her 
uterine  disease,  added  to  other  causes  of  mental  disturbances, 
was  thought  to  have  made  her  insane.  Furthermore,  not 
a  few  cases,  whose  history  of  previous  uterine  disease  I  ob- 
tained through  friends,  were  found,  on  examinations  made  at 
the  asylum,  to  have  recovered. 

Since  functional  uterine  diseases  are  ameliorated  or  cured 
when  a  woman  becomes  insane,  psychologists  have  naturally 
enough  attached  but  little  importance — from  the  point  of  view 
of  complications — to  them  compared  with  the  coexisting  men- 
tal affections.  Those  who  claim  that  the  class  of  diseases  now 
under  discussion  require  but  little  notice  in  insane  patients 
utter  but  a  fraction  of  the  truth. 

Again,  those  who  claim  that  the  progress  of  organic  uterine 
disease  is  at  all  influenced  by  insanity  are  as  far  wrong  as  the 
gynecologist  who  believes  that  the  large  majority  of  women 
who  lose  their  reason  do  so  on  account  of  disease  of  the  sexual 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  335 

organs,  or  those  who  insist  that  all  insane  women  should  be 
placed  in  charge  of  a  specialist  for  diseases  of  women.  Once 
we  have  established  the  fact  that  an  insane  woman  has  no 
organic  uterine  disease,  we  have  done  pretty  nearly  all  the 
service  that  it  is  possible  to  render.  After  the  diagnosis  of 
functional  disease  is  made,  the  patient  can  and  should  be  left 
in  charge  of  the  psychologist.  All  local  treatment — except 
hygienic — should  be  abandoned,  and  the  disturbed  function 
restored  to  its  normal  condition  by  improving  the  general 
health  or  by  the  cure  of  the  alienation. 

Right  here  I  may  observe  that  the  above  rules  hold  per- 
fectly good  when  the  functions  of  the  sexual  organs  are 
deranged  from  any  exhausting  disease — notably  phthisis 
pulmonalis. 

There  remains  a  class  of  cases,  functional  for  the  most 
part,  to  which  the  general  statements  that  have  just  been 
made  are  not  applicable.  Here  we  find  manifestations  of  in- 
sane sexual  desire,  or  obscene  and  licentious  ravings.  The 
origin  of  such  cases  is  often  some  disease  or  abuse  of  the 
sexual  organs  ;  and  the  abnormal  condition  may  have  disap- 
peared, or,  if  existing,  may  be  subtle  enough  to  elude  the 
diagnostic  skill  of  the  physician.  True,  mental  derangement, 
in  such  instances,  may  seem  to  indicate  trouble  of  the  pelvic 
organs ;  but  no  disease  can  be  detected,  and  no  local  treat- 
ment avails.  Care  must  be  directed  to  the  nervous  system, 
for  the  disease  is  centric,  not  reflex.  It  is  of  course  under- 
stood that  while  manifestations  of  sexual  excitement  can 
originate  in  the  brain  or  nervous  system,  identical  symptoms 
can  be  induced  by  disease  of  the  pelvic  organs.  One  can 
scarcely  overestimate  the  importance  of  sharply  differentiat- 
ing diseases  of  the  sexual  organs  that  either  cause  or  stimu- 
late insanity  from  mental  derangements  which  occur  quite 
independent  of  other  visceral  lesions. 

In  concluding  this  matter  I  desire  to  repeat  that  abnormal 
sexual  excitement  sometimes  has  its  origin  in  the  nerve 
centers,  and  this  too  when  the  sexual  organs  are  free  from  all 
disease  ;  and  also  that  a  mental  derangement  of  an  emotional 


336  MEDICAL  GYNECOLOGY. 

character  may  persist  when  the  causative  disease  has  sub- 
sided. Although  non-interference  with  functional  diseases  of 
insane  women  is  the  rule,  yet  when  the  alienated  suffer  from 
organic  diseases,  they  have  the  right  to  all  the  relief  that 
gynecology  can  afford — and  this  is  vevy  much. 

In  this  connection  the  first  question  confronting  us  is, 
What  is  the  ascertained  effect  upon  the  insane  of  cura- 
tive treatment  applied  to  coexistent  disease  of  the  sexual 
organs  ? 

The  roseate  views  resulting  from  a  perusal  of  modern 
medical  literature  are  somewhat  delusive.  The  results  are 
not  so  gratifying  and  wonderful.  We  hear  of  all  kinds  of 
strange  nervous  affections  and  mental  perturbations  that 
disappear  most  magically  on  the  restoration  of  a  laceration  of 
the  cervix,  or  when  a  dislocated  uterus  is  replaced.  It  is 
tempting  to  take  as  a  cause,  what  is  simply  a  synchronous 
occurrence  ;  but  coincidence  is  not  always  cause.  Moreover, 
it  is  unsafe  to  believe  that  a  prompt  restoration  of  sense  and 
reason  occurs  in  insane  women  when  a  uterine  or  ovarian 
disease  is  cured. 

My  investigations  led  to  this  conclusion :  In  a  large  ma- 
jority of  cases  acute  affections  of  the  brain  and  nervous 
system,  originally  due  solely  to  disease  of  the  sexual  ograns, 
will  be  relieved  when  the  primary  affection  disappears  or  is 
cured.  The  result  of  treatment  of  the  pelvic  condition  will 
be  in  direct  proportion  to  the  severity  and  duration  of  the 
mental  derangement.  We  may  nearly  always  expect  marked 
benefit  or  prompt  recovery  in  subacute  mania  caused  or  aggra- 
vated by  maladies  of  the  sexual  organs  ;  but  chronic  mania 
with  similar  causes  and  associations  quite  frequently  remains 
unaffected  after  the  local  disease  has  disappeared.  This,  too, 
is  frequently  the  case  when  the  general  health  of  the  patient 
has  improved  by  local  treatment.  In  general  pathology, 
when  two  or  more  diseases  are  bound  by  the  relationship  of 
cause  and  effect,  the  secondary,  unfortunately^  does  not 
always  disappear  when  the  primary  one  is  removed. 

I  have  endeavored  to  limit  the  boundary  line  of  success 


SEX  AND  ITS   RELATIONS  TO   INSANITY.  337 

which  the  gynecologist  may  expect  to  reach  in  practice  among 
the  insane. 

The  diagnosis  of  diseases  of  the  sexual  organs  in  the  in- 
sane is  beset  with  endless  difficulties  ;  no  line  of  practice  for 
diagnosticating  these  conditions  in  the  alienated  has  yet 
been  laid  down  in  text-books,  save  in  part,  so  that  much  of 
my  study  was  devoted  to  the  means  of  ascertaining  the  clin- 
ical history  and  physical  indications  of  the  state  of  the  sexual 
organs  in  those  under  my  charge. 

The  first  thing  required  is  a  natural,  clinical  history  of  the 
sexual  system,  and  very  few  insane  can  give  any  account 
of  themselves  in  this  regard.  Even  those  who  understand, 
and  are  ready  to  answer  questions  about  their  bodily  con- 
dition, reluctantly  discuss  anything  pertaining  to  the  genitals  ; 
and  when  they  are  induced  to  do  so,  one  does  not  know  how 
far  to  rely  upon  the  data  obtained.  Hence,  as  in  the  case  of 
children,  we  must,  perforce,  rely  on  the  story  told  by  those 
about  them — relatives,  friends,  or  attendants.  The  leading 
points  in  the  patient's  history  can  thus  usually  be  elicited 
upon  careful  cross-questioning,  and  much  may  be  gained, 
provided  the  attention  of  the  nurse  or  attendant  can  be  di- 
rected intelligently  to  the  state  of  the  uterine  function. 

How  sadly  the  condition  of  the  reproductive  system  has 
been  neglected  is  best  shown  by  an  inspection  of  the  asylum 
records.  In  these,  all  that  seems  of  importance  is  the  noting 
of  age,  marriage,  or  otherwise,  and  the  number  of  children. 
And,  more  than  this,  the  age  record  is  usually  kept  in  de- 
cades, so  that  we  know  not,  even  statistically,  the  relations 
between  insanity  and  puberty,  menopause  or  active  func- 
tional period. 

To  obviate  much  of  this  difficulty  and  to  gather  all 
that  was  possible  in  the  way  of  aid  to  the  student  of  dis- 
eases of  women,  I  devised  and  arranged  a  case  book  for  our 
county  asylum  that  was  approved  by  the  medical  director, 
Dr.  Shaw.  The  headings  are  so  arranged,  on  the  blank  pages, 
as  to  call  out  the  history  bearing  directly  on  the  condition  of 
the  sexual  system,  and  if  filled  out  with  care  gives  informa- 


338  MEDICAL  GYNECOLOGY. 

tion  upon  all  the  questions  raised  in  the  above  discussion. 
See  Diseases  of  Women  (Skene). 

This  is  not  all  that  is  desirable,  but  I  believe  it  the  best 
attainable  to  supply  records  not  only  for  the  jDurposes  of  diag- 
nosis, but  also  that  the  patients  may  have  the  correct  skilled 
treatment  of  those  who  devote  themselves  to  this  branch  of 
the  science  of  medicine. 

The  method  tries  to  elucidate  the  relation  of  the  mental 
derangement  to  the  functions  of  reproduction,  and  to  dis- 
cover, as  far  as  possible,  the  condition  of  the  sexual  organs 
before  insanity  occurred.  The  state  of  the  menstrual  function 
then  shows,  as  a  rule,  the  history  of  the  uterine  condition ; 
and,  at  the  end,  we  note  such  mental  manifestations  as  may 
indicate  the  existence  of  disease  of  the  sexual  organs.  Here 
I  advocate  the  careful  observation  of  the  speech  and  behavior 
of  insane  women  as  helps  to  diagnosis  ;  and  the  following 
cases  may  briefly  be  mentioned  in  this  connection  : 

My  attention  was  called  by  Dr.  Shaw  to  a  girl  who  walked 
about  the  ward  in  a  stooping  position,  holding  her  hands  upon 
the  genitals  as  if  trying  to  support  them.  She  did  not  com- 
plain at  all,  and  she  was  not  sane  enough  to  answer  questions 
about  herself ;  her  actions,  however,  led  to  the  notion  that 
something  was  wrong,  and  it  was  found  upon  an  examination 
that  she  had  uterine  disease.  In  another  case,  that  of  a  mar- 
ried woman  who  had  borne  children,  there  was  an  ability  to 
converse  quite  reasonably  on  very  many  subjects,  yet  this 
woman  was  greatly  disturbed  by  imagining  that  men  visited 
her  at  night  for  unlawful  purposes  ;  and  a  physical  examina- 
tion revealed  disease  of  the  uterus. 

There  are  very  many  ways  in  which  cerebration  reveals 
how  the  brain  is  influenced  by  the  sexual  organs  ;  and  this 
derangement,  very  often  shown  by  abnormal  conversation,  is 
valuable  in  so  far  as  it  points  to  disease  of  the  pelvic  organs. 
Yet  disease  of  these  organs  is  not  always  indicated  by  obscene 
or  licentious  actions  or  expressions.  The  demoralization 
of  the  insane  may  arise  from  former  bad  habits  and  asso- 
ciations ;    or,   again,  it  may   be  developed  by  some   disease 


SEX  AND   ITS  RELATIONS  TO   INSANITY.  339 

of  the  nerve  centers  while  the  sexual  organs  are  perfectly 
normal. 

Perverted  thoughts,  when  the  control  of  the  reason  is  in- 
hibited, may  be  very  marked  and  attractive,  and  yet  there 
may  be  no  physical  evidence  of  disease  ;  and,  save  disease  of 
the  brain,  the  patient  may  be  well.  Nevertheless,  when  de- 
ranged emotions,  manifested  by  obscene  speech  or  action,  are 
observed  in  those  previously  modest  and  chaste,  these  should 
be  taken  as  evidence  of  disease  of  the  sexual  organs,  and 
should  lead  to  further  investigation. 

Physical  exploration  of  the  pelvic  organs  of  insane  women 
has  always  been  attended  with  numerous  difficulties  ;  indeed, 
it  has  been  impossible  to  hold  examinations  on  some  insane 
patients.  Persuasion  is  futile  and  force  generally  defeats  the 
ends  of  the  examiner,  at  the  same  time  often  resulting  in 
injury  to  both  patient  and  physician.  The  only  practical 
method  has  been  ansesthetization  by  ether,  and  the  outcome 
is  very  unsatisfactory.  It  is  a  difficult  undertaking  to  admin- 
ister ether  or  chloroform  to  a  maniac  without  regard  to  the 
dangerous  results.  We  need  not  then  be  surprised  that  those 
having  the  care  of  insane  women  should  have  been  very 
chary  in  the  practice  of  gynecology.  The  force  necessary  to 
give  ether  to  a  maniac  for  the  purpose  of  treating  a  uterine 
disease  is  simply  distressing,  and  the  results  do  not  justify 
the  means. 

My  purpose  is  admirably  accomplished  by  the  use  of 
nitrous-oxide  gas  as  an  ansesthetic.  It  is  quick  and  pleasant 
in  its  action,  and  that  choking  sensation  so  distressing  to  the 
sane,  and  particularly  terrifying  to  the  insane,  is  not  induced. 

The  method  of  its  administration  is  that  pursued  by  the 
dental  surgeons,  to  whom  for  this,  as  well  as  for  other  most 
valuable  mechanical  appliances  which  physicians  habitually 
use,  we  are  under  deep  obligations.  A  rubber  cap  which 
covers  the  patient's  mouth  and  nose  is  used,  instead  of  the 
usual  mouthpiece.  The  gas  is  administered  to  the  more 
tractable  patients  while  on  the  table,  and  unmanageable  ones 
are  placed  in  a  high-backed  chair.     The  physician  places  the 


34:0  MEDICAL  GYNECOLOGY. 

cap  over  the  face,  an  assistant  on  either  side  holds  each  an 
arm,  the  third  firmly  pressing  and«  steadying  her  head  against 
the  chair. 

Complete  anaesthesia  is  then  very  quickly  obtained,  since 
the  most  refractory  among  them  are  usually  quieted  after  a 
few  inhalations.  To  avoid  the  deep  anaesthesia  and  conse- 
quent arrest  of  blood  aeration  accompanying  this  procedure, 
it  is  best  to  admit  some  air  by  opening  the  valves,  thus  pro- 
longing the  patient's  unconsciousness.  The  ensuing  lividity 
— always  a  result  of  this  extreme  anaesthesia— should  be 
avoided,  for  the  reason  that  the  tissues  become  thereby 
changed  in  appearance,  thus  preventing  an  accurate  minute 
observation,  especially  so  when  the  examiner  is  not  thorough- 
ly accustomed  to  his  work. 

Nitrous-oxide  gas  has  not  been  followed  by  the  slightest 
unpleasant  effects,  at  least  so  far  as  the  observations  of  Drs. 
Shaw  and  Arnold,  of  the  Flatbush  Asylum,  have  extended, 
and,  furthermore,  the  mental  state  of  not  a  few  of  the  pa- 
tients who  took  it  seemed  to  be  decidedly  improved  after  its 
administration.  One  young  girl,  an  inmate  of  the  asylum 
for  months,  whose  time  was  absolutely  unoccupied  physically 
and  mentally,  actually  asked  for  work  to  do  subsequent  to 
several  inhalations  of  nitrous-oxide  gas.  Now,  the  local 
treatment  for  her  condition  had  not  proved  of  the  slightest 
benefit,  either  to  her  physical  derangement  or  in  her  aliena- 
tion. Hence,  the  improvement  could  not  have  arisen  but  from 
the  use  of  the  agent  in  question.  There  are,  also,  cogent 
reasons  for  regarding  the  nitrous-oxide  gas  as  being  a  most 
valuable  tonic  in  cases  of  extreme  exhaustion  of  the  nerve 
centers,  and  in  general  debility  of  the  cerebro- spinal  system. 

In  the  New  York  Obstetrical  Society  some  very  pertinent 
and  instructive  cases  about  this  new  nerve  tonic  were  related 
by  Drs.  Barker  and  Blake,  both  gentlemen  administering  the 
gases  in  such  small  doses  that  anaesthesia  did  not  ensue, 
whereupon  the  results  were  most  satisfactory.  Further  ex- 
perimentation and  observation  will,  I  believe,  show  that  an 
equal  amount  of  benefit  will  follow  when  the  gas  has  been 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  34,1 

given  as  an  anaesthetic  and  when  a  dual  purpose  is  served ; 
and  when  these  purposes  are  so  pre-eminently  important,  and 
when  the  results  obtained  are  synchronous,  it  seems  to  me  that 
extended  investigation  is  demanded  wherever  any  number  of 
the  insane  are  kept  in  public  or  private  institutions.  At  any 
rate,  in  the  domain  of  the  diseases  of  women  it  promises  the 
greatest  benefit. 

The  physical  signs  of  disease  vary  little,  if  any,  from 
those  elicited  on  examination  of  a  sane  woman,  save  in  one 
or  two  important  instances.  We  could  not  expect  the  percus- 
sion note  to  alter  its  pitch,  because,  forsooth,  percussion  was 
performed  on  one  whose  mind  was  deranged,  nor  would  the 
size  and  shape  of  any  superficial  distortion  be  otherwise  if 
observed  in  a  sane  or  insane  woman. 

Palpation,  however,  is  marked  almost  always  by  an  ab- 
sence of  tenderness  ;  and  this  is  noticeable  even  in  those  who 
undergo  examinations  without  an  anaesthetic  being  given. 
It  is  rare,  indeed,  that  patients  complain  of  having  been  hurt 
by  an  examination  or  subsequent  treatment. 

Inspection  reveals  a  pale  and  anaemic  condition  of  the 
vagina  and  cervix  uteri  whenever  the  mental  derangement 
has  existed  for  several  months  and  there  has  been  amenor- 
rhoea,  the  appearances,  indeed,  all  being  those  of  one  who 
has  passed  the  menopause.  This  must  not  be  looked  upon 
as  any  evidence  of  active  disease,  but  only  as  exhibiting  how 
inactive  is  the  circulation  and  who  poor  is  the  nutrition. 

The  rectum  is  almost  always  distended  in  insane  women, 
since,  be  it  remembered,  constipation  is  almost  invariably 
present  in  this  class  of  patients.  It  should  always  be  a  rule 
to  thoroughly  empty  the  bowels  before  making  an  examina- 
tion, so  as  to  be  rid  of  one  of  the  chief  obstacles  in  our  inves- 
tigation. 

Ovarian  disease — difficult  at  all  times  to  diagnosticate — is 
especially  so  in  the  insane.  Tenderness  on  pressure,  we  all 
know,  is  a  most  valuable  symptom  in  ascertaining  the  condi- 
tion of  the  ovaries ;  and  in  the  insane  the  administration  of 
an  anaesthetic  completely  bars  out  all  chance  of  obtaining  the 


342  MEDICAL  GYNECOLOGY. 

information  on  this  score.  And,  further,  if  this  class  of  pa- 
tients are  examined  without  nitrons  oxide,  we  can  not  always 
tell  from  their  behavior  whether  pain  and  tenderness  exist  or 
not,  nor  can  we  always  believe  what  they  say. 

Palpation^  however,  revealed  to  me  in  one  case  disease 
of  the  right  ovary  ;  for,  on  strong  j)ressure,  the  organ  was 
found  enlarged,  prolapsed,  and  tender.  Rigidity  of  the  ab- 
dominal muscles  on  the  same  side  was  found,  and  this  was 
in  marked  contrast  to  their  condition  on  the  left  side. 

The  treatment  of  diseases  of  the  reproductive  organs  of 
insane  women  is  based  upon  the  general  principles  which 
guide  the  physician  in  ordinary  practice.  There  are,  how- 
ever, circumstances  j)eculiar  to  this  class  of  patients  which 
must,  of  necessity,  modify  our  treatment,  and  therefore  I 
shall  mention  some  facts  of  clinical  observation  which  are 
worthy  of  notice.  While  discussing  functional  disease,  such 
as  amenorrhoea,  it  was  claimed  that  constitutional  treatment 
alone  was  required  in  such  cases,  which  is  doubtless  true. 
Local  treatment  can  accomplish  very  little  to  relieve  such 
conditions,  either  among  the  insane  or  the  sane.  Persistent 
amenorrhoea  seldom  yields  to  local  treatment,  such  as  stem 
galvanic  pessaries,  the  local  use  of  electricity,  leeching  and 
blistering  the  uterus  ;  and  the  difficulties  in  the  way  of  em- 
ploying such  methods  among  the  insane  practically  exclude 
their  use. 

In  the  management  of  cervical  endometritis  it  is  necessary 
to  use  means  that  do  not  require  frequent  repetition.  On  that 
account  the  hot-water  douche  (a  most  valuable  remedy)  can 
not  be  used,  because  these  patients  will  not  permit  the  nurse 
to  treat  them,  nor  will  they,  except  in  rare  cases,  nse  it  them- 
selves. There  is  the  same  objection  to  the  use  of  the  cotton- 
and-glycerin  tampon,  which  requires  to  be  renewed  every 
day.  In  such  cases  I  have  used  with  advantage  an  applica- 
tion of  equal  parts  of  tincture  iodine  and  carbolic  acid  once 
a  week.  This  is  a  sedative,  and  also  changes  the  abnormal 
action  of  the  mucous  membrane,  causing  a  diminution  of  the 
leucorrhoeal  discharge,  the  erosion  of  the  surface  disappearing, 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  343 

not  by  being  replaced  by  cicatricial  tissue,  but  by  the  restora- 
tion of  normal  epithelium.  When  improvement  begins  it  is 
well  to  lessen  the  proportional  quantity  of  the  acid. 

Vaginitis  is  also  a  difficult  disease  to  treat  among  insane 
women,  owing  to  the  same  objections  to  the  vaginal  douche. 
Little  progress  can  be  made  in  the  management  of  this  affec- 
tion without  thorough  cleanliness,  and  that  is  difficult  to  ob- 
tain in  insane  patients.  In  fact,  vaginitis  and  vulvitis  occur 
of  tener  in  Xhis  class  of  patients  than  in  those  of  sound  mind, 
owing  apparently  to  want  of  care  in  keeping  the  parts  clean. 
Some  of  the  most  marked  cases  of  purulent  vaginitis  that 
have  ever  come  under  my  observation  were  among  my  patients 
in  the  asylum. 

The  treatment  adopted  in  these  cases  consisted  in  first 
thoroughly  cleansing  the  mucous  membrane  with  a  sponge, 
and  then  applying  a  mild  solution  of  nitrate  of  silver,  or  sul- 
phate of  zinc  with  fluid  extract  of  hydrastis  canadensis  and 
water,  and  then  introducing  a  tampon  of  marine  lint  which 
was  changed  for  a  new  one  every  two  or  three  days,  until  the 
inflam_mation  subsided.  The  tampon  is  sufficient  to  cure  most 
cases  of  vaginitis  without  any  other  treatment.  It  sepa- 
rates the  inflamed  surfaces,  and,  by  absorbing  the  secretions, 
keeps  the  parts  perfectly  clean.  The  tar  which  it  contains 
is  one  of  the  most  useful  remedies  in  inflammations  of  mu- 
cous membranes,  and,  besides,  fulfills  a  modern  demand  in 
surgery  in  being  antiseptic.  This  method  of  treating  vagi- 
nitis has  been  tried  in  general  practice  and  answers  well,  but 
it  is  among  the  insane  where  its  value  is  most  marked. 

Endometritis  polyposa,  or  fungosa,  with  the  menorrhagia 
which  is  caused  thereby,  is  quite  a  common  affection  among 
the  insane.  Judging  from  the  number  of  cases  which  have 
come  under  my  own  observation.  To  meet  the  indications 
and  the  many  conditions  which  the  accompanying  insanity 
gives  rise  to,  I  have  adopted,  with  satisfactory  results,  the 
following  method  of  treatment : 

Having  made  a  positive  diagnosis,  a  small  curette  or  scoop 
with  a  flexible  stem  is  carried  into  the  cavity  of  the  uterus. 


344  MEDICAL  GYNECOLOGY. 

and  the  whole  of  the  fungous  material  is  broken  down  and 
removed.  This  simple  operation  is  often  followed  by  com- 
plete recovery.  Sometimes  the  polypoid  growth  returns  and 
a  repetition  of  the  operation  is  necessary.  In  a  very  few  cases 
it  has  returned  again  and  again,  but  has  finally  yielded  to  bi- 
chloride of  mercury  given  in  the  usual  doses,  and  to  the  appli- 
cation of  tincture  iodine  and  carbolic  acid  after  the  use  of  the 
curette.  There  is  nothing  new  in  this  method  of  treating  the 
disease  in  question,  except  in  omitting  preliminary  dilatation 
of  the  cervix  by  tents.  This  is  entirely  unnecessary  and 
should  be  avoided,  because  it  is  painful  and  dangerous,  while 
the  use  of  the  blunt  scoop  is  less  likely  to  give  after-trouble 
than  any  other  form  of  intrauterine  treatment  that  I  am 
familiar  with. 

The  methods  of  treating  this  affection  given  in  our  books 
are  first  to  dilate,  use  the  curette,  and  finally  apply  some 
caustic  or  alterative  application  to  the  whole  endometrium. 
This  demands  that  the  patient  should  be  confined  to  bed 
several  days,  care  being  taken  to  prevent  the  development 
of  inflammation,  of  which  there  is  always  danger.  Such 
practice  is,  however,  impossible  among  the  insane,  as  there 
are  few  of  that  class  of  patients  who  can  be  kept  quiet  in 
bed  while  undergoing  such  treatment.  But  the  same  object 
can  be  attained  without  interrupting  the  patient  in  her  usual 
mode  of  life.  I  have  used  the  curette  in  office  practice  with 
as  little  caution  as  I  make  mild  applications  to  the  cervical 
canal,  and  so  far  have  had  no  accidents.  In  the  confidence 
based  upon  that  experience  the  treatment  was  employed 
among  the  insane,  and  the  results  have  been  quite  satisfactory. 

With  regard  to  lacerations  of  the  cervix  uteri  in  the  in- 
sane, I  have  simply  to  say  that  the  evil  that  such  lacerations 
give  rise  to  are  well  enough  known  to  warrant  us  in  declaring 
that  any  patient  with  that  complaint,  whether  sane  or  insane, 
has  a  right  to  claim  relief  at  the  hands  of  the  gynecologist. 
The  success  of  the  operation  depends  to  some  extent  upon  the 
details  of  after-treatment,  such  as  rest  in  bed  and  cleanliness. 
This  is  difficult  to  obtain  among  insane  women,  but  in  lieu  of 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  345 

that  I  have  employed  a  method  of  operating  which  gives  fair 
results,  even  when  the  patient  goes  around  during  the  healing 
process,  to  wit :  the  use  of  silk  sutures  and  the  lint  tampon 
in  place  of  the  douche. 

The  advantage  is  that  these  sutures  can  not  wound  the 
vagina  like  the  ends  of  a  silver-wire  suture,  and  the  tampon 
supports  the  uterus  and  guards  against  putting  a  strain  upon 
the  sutures  when  the  patient  moves  or  sits  up.  This  method 
is  well  adapted  to  practice  among  the  insane.  While  I  would 
hesitate  to  operate  in  the  usual  way  upon  an  insane  patient, 
I  have  practiced  the  method  described  with  marked  success. 
A  question  may  be  raised  as  to  the  propriety  of  leaving  a  silk 
suture  in  the  cervix  during  the  time  requisite  for  healing. 
The  constant  heat  and  moisture  to  which  the  suture  is  ex- 
posed certainly  favor  decomposition  of  the  silk,  and  if  that 
should  occur  the  suture  would  cause  suppuration.  I  have 
demonstrated  that  no  such  results  need  be  feared  when  the 
silk  is  properly  prepared  by  immersing  it  for  several  hours  in 
a  composition  of  melted  wax,  salicylic  and  carbolic  acids.  I 
have  removed  such  a  suture  from  the  cervix  that  had  been 
there  for  one  year  two  months  and  twenty  days.  The  patient 
was  operated  upon,  and  when  removing  the  sutures  after 
union  had  taken  place  I  carelessly  missed  one.  She  soon 
became  pregnant,  and  six  weeks  after  confinement  she  called 
for  examination  to  ascertain  the  effect  of  delivery  on  the  cer- 
vix, and  I  then  found  the  missing  suture.  It  had  caused  no 
great  trouble,  and  was  in  a  very  good  state  of  preservation. 

The  pelvic  pain  or  neuralgia  which  arises  from  cicatrices 
of  the  cervix  and  vagina  is  often  very  annoying,  and  calls 
for  treatment.  Marked  relief  follows  after  dividing  the  bands 
of  cicatricial  tissue.  In  two  insane  cases  I  have  now  in  mind 
this  treatment  was  the  only  means  that  could  easily  be  em- 
ployed, and  the  results  were  very  satisfactory.  One  was  a 
case  of  scar  tissue  of  the  cervix  from  the  reckless  use  of  nitrate 
of  silver  ;  the  other  had  a  number  of  cicatricial  bands  in  the 
vagina  resulting  from  gangrenous  vaginitis  occurring  after 
scarlatina  in  girlhood. 


346  MEDICAL  GYNECOLOGY. 

Displacement  of  the  uterus— i.  e.,  prolapsus  and  versions — 
can  be  treated  with  good  results,  excepting  when  there  are 
anatomical  or  functional  imperfections  of  the  perineum. 
The  displaced  uterus  can  be  readily  restored  and  a  pessary 
adjusted  while  the  patient  is  anjBsthetized.  It  is  necessary  to 
frequently  examine  such  patients  while  wearing  pessaries,  be- 
cause they  may  suffer  without  complaining. 

The  most  imi^ortant  difficulty  is  encountered  in  the  man- 
agement of  displacements  in  those  having  an  imperfect  peri- 
nsenm.  Pessaries  or  supports  held  in  place  by  being  fastened 
to  the  body  can  not  be  used,  and  on  that  account  we  are 
limited  to  intra  vaginal  pessaries,  which  require  the  presence 
of  the  perinffium.  To  restore  a  lacerated  perinseum  would  be 
easy,  but  to  secure  the  after-treatment,  necessary  to  a  good 
result  is  often  difficult.  Investigation  of  this  subject  among 
the  insane  has  been  very  limited,  but  I  am  satisfied  that  in 
many  cases  the  restlessness  of  such  patients  would  render  the 
use  of  the  silver  wire  unsatisfactory.  I  believe  that  the  use 
of  silk  would  be  a  great  improvement  in  these  plastic  opera- 
tions among  the  insane.  Attention  is  called  to  this  subject 
as  a  field  inviting  exx^erimentation. 

Flexion  of  the  uterus,  in  its  various  forms,  gives  rise  to 
much  suffering  when  the  menstrual  function  continues,  and 
dysmenorrhoea  is  a  common  result.  In  quite  a  number  of  pa- 
tients with  flexion  there  is  amenorrhoea,  and  in  these  flexion 
alone  is  presumed  to  give  no  trouble.  There  is  no  reason  for 
believing  that  a  flexion  unassociated  with  any  other  disease  of 
the  uterus  would  give  rise  to  disturbance  of  the  brain  or  nerv- 
ous system  in  a  i)atient  who  does  not  menstruate  ;  so  I  have 
avoided  local  treatment,  believing  that  nothing  would  be 
gained  by  anything  that  could  be  done.  But  when  the 
menses  recur,  and  are  painful,  the  probabilities  are  that  the 
flexion  is  the  cause  of  the  dysmenorrhoea,  and  it  should,  if 
possible,  be  relieved.  Knowing  how  difficult  flexions  are  to 
cure,  when  the  circumstances  are  favorable,  it  need  hardly  be 
stated  that  the  treatment  of  such  deformities  in  the  insane 
is  often  very  unsatisfactory.     The  most  daring  gynecologist 


SEX  AND  ITS  RELATIONS  TO  INSANITY.  347 

would  hesitate  to  use  a  stem  pessary,  or  perform  division  of 
the  cervix,  in  a  patient  who  could  not  be  well  controlled  dur- 
ing the  after-treatment.  In  flexion  of  the  cervix  division 
might  be  practiced  in  patients  not  too  violent  and  uncon- 
trollable. As  a  rule,  however,  the  treatment  in  such  cases 
is  limited  to  subduing  any  excessive  irritability  of  the  uterus, 
and  securing  a  sufficient  size  of  the  canal  by  dilatation  or  in- 
cision, if  necessary,  and  in  cases  of  forward  flexion  of  the 
body  muclj  might  be  gained  by  straightening  the  uterus  and 
keeping  it  so,  as  far  as  possible,  by  means  of  Thomas's  ante- 
flexion pessary,  or  some  similar  instrument. 

There  are  forms  of  dysmenorrhoea  (not  dependent  upon 
flexion  of  the  uterus  or  any  known  mechanical  cause)  that 
are  presumed  to  arise  from  ovarian  disease,  or  some  abnormal 
condition  of  the  nerves  supplying  the  sexual  organs.  In 
these  cases  the  local  signs  are  negative,  and  the  only  true  evi- 
dence of  the  painful  menstruation  is  the  fact  that  the  insanity 
is  aggravated  at  that  time,  and  the  patient  may  indicate  by 
the  position  of  the  body,  and  by  placing  the  hands  over  the 
lower  portion  of  the  abdomen,  that  the  seat  of  suffering  is  in 
the  pelvis.  For  cases  of  this  kind  I  know  of  no  special  local 
treatment  that  is  beneficial.  Fortunately,  this  form  of  dys- 
menorrhoea is  rare  among  the  insane.  The  reason  for  this  is 
that  the  tender  and  irritable  uterus  and  ovaries  are  relieved, 
in  some  cases  at  least,  upon  the  advent  of  insanity. 


23 


CHAPTER  XXVII. 

affectiojS'S  of  the  MA:*I3IAET  glaxds. 

Diseases  of  the  mammse  belong,  to  a  great  extent,  to  tlie 
domain  of  surgery,  but  there  are  some  of  these,  so  far  as 
treatment  is  concerned,  that  come  under  the  care  of  the  gyne- 
cologist. The  mammary  glands  are  sexual  organs  in  the 
sense  that  they  are  concerned  in  reproduction,  and  are  in- 
timately related  to  the  uterus  and  ovaries.  This  intimate 
relationship  between  the  pelvic  organs  and  the  mammae  is 
seen  in  the  influence  of  the  former  in  causing  diseases  and 
functional  disorders  of  the  latter.  In  a  less  degree  the  mam.- 
mary  glands  affect  the  other  sexual  organs.  This  is  exempli- 
fied in  the  affect  of  nursing,  in  causing  contraction  of  the 
uterus  post  partum,  and  in  aiding  involution. 

The  affections  which  come  within  the  scope  of  the  present 
work  are  certain  forms  of  maldevelopment ;  occasional  swell- 
ings, neuralgia,  deranged  secretion,  and  hyperplasia,  I  have 
given  the  latter  name  to  an  affection  of  the  breasts  which  is 
not  uncommon,  and  which  has  not  been  described  so  far  as  I 
know. 

Anomalies  of  Development. — The  development  of  the  mammary 
glands  depends  upon  the  same  influences  as  those  which  gov- 
ern the  development  of  the  ovaries  and  uterus.  This  intimate 
relationship  between  the  sexual  organs  is  shown  in  the  fact 
that  anomalies  of  development  of  the  mammse  are  generally 
accompanied  by  malformations  of  the  pelvic  organs.  In  a 
case  of  total  absence  of  the  uterus  Saxinger  found  both 
mammae  wanting.  A  number  of  cases  are  recorded  in  which 
the  breasts  remain  the  same  as  they  are  before  puberty,  and 

348 


AFFECTIONS  OF  THE  MAMMARY  GLANDS.  349 

the  ovaries  are  imperfectly  developed.  Winckel  has  reported 
a  case  in  which  the  right  mamma  was  normal  in  size,  but  the 
left  was  not  larger  than  that  of  a  child.  The  pelvic  organs 
were  normal,  Winckel  states,  but  of  course  it  is  possible  that 
the  left  ovary  was  defective.  It  is  equally  possible  that  the 
arrest  of  development  of  the  left  breast  was  caused  by  inflam- 
mation soon  after  birth  (a  common  affection  among  infants), 
and  the  structures  of  the  gland  were  so  destroyed  as  to  pre- 
vent further  development. 

Supernumerary  mammary  glands  are  occasionally  seen. 
This  anomaly  of  development  appears  to  arise  from  a  derange- 
ment or  arrest  of  involution — not  an  arrest  of  development, 
but  a  polymazia  and  a  lapsing  toward  a  lower  type.  These 
views  regarding  the  causation  of  anomalies  of  development  are 
based  upon  the  fact  that  the  human  female  embryo  contains 
the  germs  of  five  mammse — two  situated  in  the  middle  of 
each  side  of  the  thorax,  one  in  each  axilla,  and  one  in  the 
median  line  beneath  the  lower  end  of  the  sternum.  This  ar- 
rangement corresponds  exactly  with  that  of  some  of  the  lower 
animals.  Gorre  saw  a  woman  with  five  mammae  of  this  primi- 
tive division.  These  anomalies  are  of  interest  chiefly  in  regard 
to  causation,  which  appears  to  be  of  three  forms :  First,  im- 
perfect or  arrested  development  of  the  ovaries  and  uterus ; 
second,  lapsing  back  to  a  lower  type,  a  derangement  of  in- 
volution ;  and,  third,  diseases  of  the  glands  in  embryo  or  soon 
after  birth,  which  ends  in  destruction  of  the  rudimentary 
gland. 

Delayed  and  Imperfect  Development. — There  is  delayed  devel- 
opment of  the  manimse  in  retarded  puberty.  When  this  de- 
layed puberty  is  due  to  circumstances  that  can  be  overcome, 
the  development  of  the  mammae  goes  on  to  completion  with- 
out any  special  treatment.  Premature  development  of  the 
mammary  glands  is  not  very  infrequent.  The  glands  become 
well  formed  for  some  time  before  menstruation  appears  and 
before  the  general  development  is  completed.  This  usually 
occurs  in  precocious  girls  in  whom  there  is  some  undue  con- 
gestion or  deranged  innervation  of  the  sexual  organs.     It  is 


350  MEDICAL  GYNECOLOGY. 

of  value  in  helping  to  make  a  diagnosis  of  premature  excite- 
ment of  the  sexual  system. 

Retracted  Nipples. — The  most  important  malformation  of  the 
breasts  is  the  non-development  of  the  nipples.  This  may  in- 
volve both  breasts  or  only  one.  The  nipple  does  not,  in  well- 
marked  cases,  appear  above  the  surface  of  the  breasts,  but  is 
retracted  so  that  there  is  a  depression  in  place  of  the  pro- 
jection. This  condition  is  simulated  in  stout  girls  by  the  adi- 
pose tissue  pushing  the  skin  out  so  that  it  rises  to  the  level 
of  the  nipple.  In  those  having  rather  short  nipples  (but  not 
defective  in  any  way)  they  are  made  to  appear  deformed  by 
the  adipose  tissue  as  referred  to.  The  causes  of  retraction  or 
non-developed  nipples  are  most  frequently  some  inflamma- 
tory affection  in  infancy,  which  shortens  the  excretory  milk 
ducts,  and  occasionally  pressure  from  corsets  worn  during 
girlhood. 

TreatTnent. — When  the  canse  is  inflammation  in  infancy 
there  is  not  much  hope  of  giving  relief.  A  great  deal,  how- 
ever, can  be  done  at  puberty  by  encouragement  to  prevent  this 
arrest  of  development  by  proper  clothing.  In  fact,  puberty  is 
the  time  to  prevent  maldevelopment  and  to  aid  in  overcoming 
any  imperfections  that  there  may  be  in  the  structure  of  the 
mammse.  Girls  are  very  often  injured  by  wearing  waists  that 
are  too  small  and  compress  the  breast.  Mothers  are  likely  to 
neglect  this  matter.  The  waists  should  be  made  with  room 
for  the  breasts  to  develop  and  grow,  and  if  the  nipple  is  de- 
fective, a  ring  pad  should  be  made  of  wool  or  cotton  and 
fastened  inside  of  the  waist  so  that  all  pressure  will  be  made 
on  the  gland  and  the  nipple  be  left  free.  If  this  fails,  and 
the  cases  are  seen  later  in  life,  efforts  should  be  made  during 
the  latter  months  of  the  first  gestation  to  bring  out  the  nipple 
by  cupping.  A  very  small  cupping  glass  or  a  breast  pump 
should  be  used,  but  very  great  care  is  necessary  in  order  not 
to  do  harm.  Very  little  traction  should  be  made— just  enough 
to  draw  the  nipple  out,  and  not  enough  to  cause  congestion 
and  injure  the  nipple.  Frequent  application,  say  once  a  day, 
is  most  useful. 


AFFECTIONS  OF  THE  MAMMARY  GLANDS.  351 

Occasional  Swellings. — The  mammse  frequently  swell  and 
become  somewhat  tender.  The  swelling,  as  usually  seen,  is 
bilateral  and  due  to  congestion.  In  rare  cases  there  may  be 
CEdema.  There  is  a  sense  of  fullness  and  tenderness ;  some- 
times there  is  pain  of  a  subacute  character.  As  a  rule,  this 
affection  comes  at  the  menstrual  period,  and  is  almost  always 
due  to  some  derangement  of  the  menstrual  function,  or  some 
ovarian  or  uterine  disease.  Immediately  after  puberty  and 
at  the  mehopause  it  is  often  observed. 

The  diagnosis  is  easily  made  by  the  fact  of  its  coming  and 
going,  in  which  it  differs  from  other  affections. 

Treatment  should  be  directed  to  the  disease  which  causes 
the  swelling  of  the  breasts,  and  the  success  will  depend  upon 
the  ability  to  cure  the  primary  trouble — such  as  painful  ovu- 
lation or  menstruation  or  some  organic  disease  of  the  pelvic 
organs.  There  is  a  form  of  enlargement  of  the  breast  which 
does  not  belong  to  the  class  of  cases  now  under  consideration, 
neither  is  it  a  hypertrophy,  such  as  is  described  in  works  on 
this  subject.  It  occurs  in  connection  with  hysteria.  Dr. 
John  C.  Shaw  has  related,  in  the  Brooklyn  Medical  Journal, 
April,  1893,  a  case  of  this  kind  from  which  I  quote  the  fol- 
lowing : 

"L.  H.,  aged  eighteen  ;  a  well-developed,  heal  thy -appear- 
ing young  woman.  Nothing  positive  is  know^n  of  her  family 
history  except  that  her  mother  is  of  an  exceedingly  nervous 
temperament.  She  was  married  at  the  age  of  sixteen  years. 
Nine  months  after  her  marriage  her  husband  was  suddenly 
killed  in  a  railroad  accident.  In  August,  1891,  while  engaged 
in  a  swimming  match,  she  was  seized  with  cramps  and  was 
carried  out  of  the  water  by  some  one  near  at  hand.  Three 
weeks  later  she  began  to  complain  of  sharp,  shooting  pain  in 
the  left  breast,  which  she  thinks  was  caused  by  an  accidental 
blow  when  she  was  being  rescued  from  the  water.  A  few 
days  after,  she  was  seized  with  a  convulsion  ;  for  twelve  weeks 
subsequent,  she  had  convulsions,  on  an  average  of  two  a 
week ;  and  during  this  time  the  left  breast  grew  larger  and 
more  painful.     She  was  now  admitted  to  the  Long  Island 


352  MEDICAL  GYNECOLOGY. 

College  Hospital,  where  she  says  an  opening  was  made  into 
the  breast  and  pus  discharged. 

"On  April  5,  1892,  she  was  admitted  to  the  Kings  County 
Hospital,  Examination  showed  the  left  breast  enlarged,  ap- 
I)earing  swollen,  oedematous,  and  somewhat  cyanotic  ;  it  is 
soft ;  there  are  no  hardened  parts  ;  no  evidence  of  tumor. 
There  is  also  the  same  oedema  of  the  left  hand  and  forearm, 
and  the  same  bluish  color  presented  by  the  breast ;  these 
oedematous  parts  are  cold  to  the  touch.  The  breast  is  in- 
tensely hypersesthetic  ;  the  slightest  touch  causes  pain.  This 
hypersesthesia  extends  from  a  short  distance  below  the  inser- 
tion of  the  breast  to  the  shoulder,  also  on  the  corresponding 
area  on  the  back  ;  it  is  confined  entirely  to  the  left  side. 
There  is  anaesthesia  of  the  anterior  surface  of  the  left  arm 
and  forearm.  All  her  internal  organs  are  perfectly  healthy, 
and  she  is  well  nourished. 

"When  our  patient  presented  herself  we  had  no  difficulty 
in  making  a  diagnosis  of  hysteria  with  oedema,  but  in  asso- 
ciation with  the  oedema  of  the  left  upper  extremity  we  also 
found  a  condition  of  the  left  mammary  gland  which  we  had 
not  the  least  hesitancy  in  pronouncing  a  hysterical  oedema 
and  analogous  to  the  oedema  of  the  arm  ;  we  wished,  however, 
to  have  the  opinion  of  a  physician  who  is  more  familiar  with 
organic  diseases  of  the  female  mammary  gland  than  we  are, 
in  that  way  to  positively  exclude  the  presence  of  any  organic 
disease  ;  we  therefore  asked  Dr.  A.  J.  C.  Skene  to  see  her. 
His  reply  after  examining  her  reads  as  follows : 

"'The  affection  of  the  mammary  gland  is  undoubtedly 
oedema.  The  most  careful  examination  reveals  no  evidence 
of  any  other  morbid  condition.  I  feel  that  T  can  speak  rather 
positively  on  this  point.  My  examination  was  made  with 
the  greatest  care,  but  not  the  slightest  evidence  could  I  find  of 
any  other  known  disease  of  the  mammary  gland. 

"  'There  is  another  very  interesting  point  connected  with 
the  case,  and  that  is  the  absence  of  any  disease  whatsoever  of 
the  pelvic  organs.  In  affections  of  the  mammary  gland  in 
women  that  I  have   seen  (excluding  malignant  disease  and 


AFFECTIONS  OF  THE  MAMMARY  GLANDS.  353 

acute  mastitis)  I  have  almost  invariably  found  some  ovarian 
or  uterine  disease,  and  I  have  taken  it  for  granted  that  the 
mammary  disease  w^as  due  to  reflex  disturbances  ;  but  in  this 
case  there  is  certainly  no  disease  of  the  sexual  organs  to  v^hich 
the  mammary  oedema  could  be  attributed. 

"  'The  oedema  in  this  patient  is  not  white,  but  bluish,  a 
cyanotic  appearance,  and  the  temperature  of  the  parts  is  low- 
ered. We  have  a  case  of  blue  oedema.  So  far  as  we  know, 
no  case  h^s  been  reported  in  which  the  oedema  has  been  in 
the  breast ;  it  has  always  been  confined  to  the  extremities — 
either  an  arm  or  leg,  most  frequently  the  arm,  and  it  is  uni- 
lateral.'" 

Derangements  of  the  Secretions  of  the  Mammse. — Unnatural  con- 
ditions of  the  secretion  of  the  breasts  is  also  a  secondary  affec- 
tion. Most  of  the  cases  are  caused  by  disease  of  the  other 
organs  of  sex,  but  others  are  due  evidently  to  abnormal  states 
of  the  general  organization, 

Galactorrhcea  is  mentioned  as  an  affection  which  occurs 
during  lactation  and  generally  soon  after  confinement.  I 
limit  my  remarks  to  a  secretion  of  milk  when  not  nursing, 
which  may  be  moderate  or  very  profuse.  This  is  a  perverted 
function  caused  by  some  primary  disease  outside  of  the  breasts 
themselves.  The  worst  case  of  this  kind  that  I  have  seen  was 
a  woman  who  had  had  several  children.  The  last  child  had 
been  weaned  over  one  year  before  I  saw  her  in  consultation 
with  her  physician.  She  then  had  a  free  flow  of  a  thin,  watery 
milk  which  continued  night  and  day.  The  patient  had 
syphilis  and  was  a  nervous  person,  but  had  no  disease  of  her 
sexual  organs,  so  far  as  I  could  find  out.  Her  physician  had 
tried  a  great  variety  of  remedies  without  effect.  The  subse- 
quent history  I  never  received.  I  recommended  the  local  appli- 
cation of  unguentum  plumbi  iodidi  to  the  breasts  and  bella- 
donna internally  in  doses  that  could  be  well  borne.  That 
treatment,  combined  with  nux  vomica,  quinine,  and  iron,  has 
helped  in  other  cases  of  a  milder  character  that  have  come 
under  my  observation.  Sometimes  benefit  has  been  derived 
from  compression,  as  recommended  by  Winckel. 


354  MEDICAL  GYNECOLOGY. 

Milk  serum  is  often  formed  in  the  breasts  along  with  dark- 
ening of  the  areola  in  uterine  fibromata  and  ovarian  tumors, 
and  sometimes  in  chronic  inflammations.  The  secretion  is 
not,  as  a  rule,  very  free,  and  is  interesting  to  the  iDhysician 
only  as  an  aid  to  diagnosis.  If  one  is  not  aware  of  this  secre- 
tion and  the  breast  signs,  pregnancy  might  be  suspected, 
w^hen  ovarian  or  uterine  neoi)lasms  is  the  affection  present. 

In  several  aged  women  I  have  found  a  pinkish  discharge 
from  one  breast  which  alarmed  the  patients,  and  the  first 
case  that  I  saw  led  me  to  suspect  malignant  disease,  although 
there  were  no  other  signs  of  any  such  affection.  The  further 
history  of  all  cases  (except  one  now  under  my  care)  showed 
that  there  was  no  malignant  disease  present.  All  the  cases 
that  I  have  seen  have  been  treated  by  local  applications  of 
tannin  and  glycerin,  and  internally  with  arsenic  and  iron  in 
medium  doses. 

Mastodynia ;  Neuralgia  of  the  Mammary  Glands. — This  affection 
is  characterized  by  neuralgic  pain,  which  recurs  at  regular  or 
irregular  intervals  and  is  not  attended  with  any  structural 
change  that  can  be  distinguished.  There  is  in  some  cases 
tenderness,  which  suggests  that  there  might  be  something  ap- 
proaching inflammation.  These  pains  have  been  attributed 
to  some  disorder  of  the  sexual  organs,  and  in  this  I  agree 
to  a  certain  extent.  I  have  seen  cases  of  neuralgia  of  the 
breast  that  appear  during  the  course  of  some  uterine  or 
ovarian  disease,  functional  or  organic,  and  then  disappear 
when  the  primary  affections  were  relieved.  This  leaves 
barely  room  for  doubt  that  the  mammary  pain  was  caused 
by  reflex  influences. 

There  is  another  class  of  cases  that  come  under  observa- 
tion and  that  do  not  have  any  ovarian  or  uterine  disease,  either 
organic  or  functional,  but  do  have  derangement  of  sexual  in- 
nervation. Sudden  cessation  of  sexual  intercourse  which  has 
been  liberally  and  for  a  considerable  time  in  practice  will  often 
be  followed  by  mammary  pain.  Overindulgence  gives  rise  to 
similar  pain.  In  malaria,  rheumatism,  and  hysteria,  pain  in 
the  mammse  is  not  uncommon. 


AFFECTIONS   OF   THE  MAMMARY   GLANDS.  355 

Treatment. — When  the  pain  is  caused  by  any  disease  of 
the  pelvic  organs,  the  only  sure  help  comes  from  removing  the 
cause.  It  is  often  necessary  to  relieve  the  pain  while  curing 
the  primary  trouble.  Local  anodynes  should  be  used,  bella- 
donna, conium,  and  cocaine  being  the  best  to  quiet  pain. 
The  two  former  may  be  used  in  the  form  of  fluid  extracts 
or  with  equal  parts  of  glycerin  applied  on  cotton.  When 
due  to  malnutrition,  tonics  give  relief  ;  when  due  to  sexual 
hypersesthesia,  exercise  and  bromides  help. 

Areolar  Hyperplasia  of  the  Mammary  Glands.— I  give  the  above 
name  to  a  condition  of  the  mammary  glands  that  I  have  care- 
fully studied  clinically,  but  have  not  had  an  opportunity  to 
investigate  the  pathological  anatomy  to  an  extent  sufficient  to 
enable  me  to  feel  sure  that  the  name  used  is  accurately  de- 
scriptive and  hence  appropriate. 

About  sixteen  years  ago  a  maiden  lady  consulted  me  about 
a  hard,  irregular  mass  in  her  left  breast.  It  was  painful  and 
tender.  She  had  suffered  for  about  two  months  from  pain 
and  tenderness,  and  more  recently  had  noticed  that  there  was 
an  enlargement  at  the  point  of  tenderness.  She  appeared  to 
be  over  forty  years  of  age,  and  was  in  fairly  good  health  and 
menstruated  regularly.  The  tumor  was  situated  in  the  outer 
side  of  the  gland,  w^as  quite  hard  and  nodulated,  and  at  one 
point  there  was  a  soft  spot  which  appeared  to  contain  fluid. 
Cancer  was  suspected,  and  surgeons  then,  as  now,  advised  am- 
putation when  there  was  reason  for  believing  the  trouble  was 
malignant.  I  removed  the  entire  breast,  and  found  in  the 
mass  two  small  cystic  cavities.  A  pathologist  examined  the 
sjDecimens  and  reported  that  there  was  an  extraordinary  de- 
velopment of  the  cellular  tissue,  that  in  places  the  blood- 
vessels and  gland  structure  were  atrophied,  and  that  the  cysts 
were  dilated,  milk  ducts  containing  a  fluid  which  appeared 
to  be  milk  serum.  There  was  no  evidence  of  cancer,  and 
the  patient  is  living  and  well  at  this  time. 

Since  then  I  have  seen  twenty -three  cases  with  a  clinical 
history  and  physical  signs  about  the  same  as  that  given  above, 
and  all  of  them  have  recovered,  excepting  two  that  are  now 


356  MEDICAL   GYNECOLOGY. 

under  treatment  and  bid  fair  to  recover.  All  these  patients 
were  fearful  of  having  cancer ;  several  of  them  came  to  be 
operated  upon,  but  none  required  surgical  treatment.  About 
one  half  of  the  number  had  some  uterine  or  ovarian  disease. 

One  case  is  worthy  of  being  recorded :  A  lady  had  cancer  of 
the  mammary  and  axillary  glands.  I  operated,  and  the  speci- 
men was  pronounced  to  be  carcinoma  by  Dr.  Frank  Ferguson. 
The  disease  returned,  and  she  died  about  two  years  after- 
ward. One  year  after  the  operation  the  sister  of  the  patient 
came  to  me  and  told  me  that  she  had  a  painful  tumor  in 
her  breast,  and  that  she  had  made  up  her  mind  to  have  it 
removed.  This  patient  was  forty-one  years  old  and  had  pro- 
lapsus uteri.  The  tumor  was  an  inch  and  a  quarter  in  diam- 
eter, hard,  irregular,  nodulated,  and  quite  tender.  Taking 
into  account  the  history  of  her  sister's  case,  I  was  satisfied 
that  the  tumor  was  cancerous,  and  decided  to  operate,  but,  as 
it  was  not  convenient  to  do  so  at  that  time,  I  put  her  under 
treatment  and  waited.  The  tumor  did  not  grow,  but,  on  the 
contrary,  appeared  to  diminish  and  became  less  painful.  The 
treatment  was  continued,  and  in  less  than  a  year  it  had  become 
much  smaller  and  gave  no  further  trouble.  It  is  now  five 
years  since  I  first  saw  her  and  she  is  quite  well.  There  is  still 
a  hardened  portion  of  the  gland,  but  it  shows  no  tendency  to 
grow,  and  is  neither  painful  nor  tender. 

Regarding  the  causation  of  this  affection  I  am  still  in  the 
dark.  In  about  half  the  cases  seen  there  was  some  affec- 
tion of  the  sexual  organs  which  might  have  caused  the  dis- 
ease of  the  breasts,  but  in  an  equal  number  there  was  no 
local  or  constitutional  disease.  Most  of  these  patients  gave  a 
history  of  having  had  a  blow  upon  the  breast,  but  not  near 
enough  to  the  point  where  the  disease  of  the  breast  appeared 
to  make  sure  that  the  cause  was  traumatic.  The  ages  ranged 
from  twenty-one  to  sixty  years,  so  that  age  does  not  seem  to 
have  any  causative  relation  to  the  affection. 

Treatment. — Daily  applications  of  equal  parts  of  tincture 
of  iodine,  opium,  and  aconite  until  the  skin  becomes  irri- 
tated, then  rest ;   and  when  the  irritation  subsides  fluid  ex- 


AFFECTIONS   OP  THE  MAMMARY  GLANDS.  357 

tract  of  conium  is  applied  twice  a  day  for  three  or  four 
weeks.  If  the  pain  and  tenderness  persist,  the  first  appli- 
cation is  again  used.  Internally  the  bromide  of  arsenic  in 
small  doses  is  used  for  a  month,  and  then  iodide  of  iron  if 
iron  is  indicated.  If  there  is  no  anaemia,  iodide  of  ammo- 
nium is  used. 


CHAPTER  XXyill. 

THE   XJTERIXE   FIBROMATA. 

It  is  to  be  regretted  that  the  causes  or  conditions  which 
give  rise  to  fibroid  neoplasms  of  the  uterus  are  not  by  any 
means  fully  understood.  It  is  known  that  certain  races — the 
African,  for  example — and  married  sterile  women,  are  more 
liable  to  these  neoplasms  than  others,  and  that  they  appear 
most  frequently  between  twenty  and  thirty- five  years  of  age 
or  thereabouts  ;  and  from  these  facts  one  is  led  to  suppose 
that  active  nutrition  of  the  sexual  organs,  with  limited  func- 
tional activity,  favors  the  coming  of  these  new  growths  of  the 
uterus.  However  this  may  be,  it  is  evident  that  the  physi- 
cian is  almost  powerless  in  removing  the  causes.  I  shall 
consider  briefly  the  medical  treatment  of  uterine  fibromata. 

A  great  revolution  has  taken  place  in  the  treatment  of 
these  growths  within  the  last  few  years.  In  former  times  it 
was  all  medical ;  now  it  is  almost  wholly  surgical.  The 
only  question  among  surgeons  at  the  present  time  is  wheth- 
er operative  interference  should  be  relied  upon  wholly,  or 
whether  in  certain  cases  electrolysis  should  be  employed. 
Without  stopping  to  discuss  this  important  question  in  full, 
I  may  say  that  certain  cases  demand  operative  interference, 
and  many  others  can  be  completely  controlled  by  the  use  of 
electricity.  But  electrolysis  as  practiced  in  the  treatment 
of  fibroids  of  the  uterus  is  a  surgical  procedure,  in  my  opin- 
ion, and  hence  I  do  not  feel  called  upon  to  discuss  that 
method  of  treatment  in  this  connection. 

In  spite  of  all  the  enthusiasm  of  surgeons,  and  the  very 
satisfactory  results  obtained  by  surgical  treatment,  as  prac- 

358 


THE   UTERINE  FIBROMATA.  359 

ticed.  by  the  most  judicious  men,  there  are  still  many  who  do 
not  require  surgical  treatment,  the  danger  and  sufferings  not 
being  sufficient  to  call  for  it,  and  some  who  refuse  operative 
treatment,  and  still  others  who  are  so  situated  that  they 
can  not  obtain  the  services  of  competent  surgeons.  Such 
cases,  consequently,  come  under  the  care  of  the  physician. 

The  medical  treatment  consists  in  removing  the  conditions 
which  favor  the  growth  of  these  fibroids.  This,  unfortu- 
nately, as  .before  referred  to,  is  exceedingly  limited.  If  in  a 
given  case  there  is  a  pronounced  sexual  appetence  and  steril- 
ity, voluntary  or  involuntary,  something  may  be  done  by 
judicious  advice  and  the  use  of  bromide  of  soda.  Diet  also 
is  presumed  to  have  some  influence  upon  the  growth  of 
fibroids.  A  limited  amount  of  animal  food,  or  a  partially 
vegetable  diet,  is  said  to  be  best.  In  fact,  I  believe  some 
time  ago  a  diet  list  was  made  out  for  cases  of  fibroids-;  but 
I  have  never  been  able  to  determine  whether  it  was  of  the 
slightest  value  or  not.  I  remember  at  the  time  I  satisfied 
myself  that  the  author  of  the  diet  evolved  it  out  of  his  inner 
consciousness,  upon  some  theory  which  he  had  regarding  the 
nutrition  of  fibroids,  and  I  am  quite  sure  that  no  observations 
have  ever  been  made  in  this  country  that  would  prove  the 
influence  of  any  certain  kind  of  diet  upon  the  growth  of 
fibroids.  In  fact,  one's  lifetime  is  hardly  long  enough  to 
make  a  sufiicient  number  of  observations  to  determine  this 
point.  It  is  rational  to  suppose,  however,  that  a  non-stimu- 
lating and  frugal  diet  might  be  best  adapted  to  this  class  of 
cases. 

The  great  difficulty  which  arises  from  the  presence  of 
fibroids  is  menorrhagia  and  pressure  upon  neighboring 
organs.  The  excessive  menstrual  flow,  of  course,  maintains 
a  condition  of  anaemia  and  general  weakness,  and  pressure 
occasionally  gives  rise  to  pain.  The  object  of  medical  treat- 
ment, then,  should  be  to  relieve  pain  without  the  use  of 
anodynes,  if  possible,  and  to  control  the  menorrhagia.  In 
regard  to  the  relief  of  pain  from  pressure,  postural  treatment 
is  the  most  effectual — that  is  to  say,  the  patient  should  not 


360  MEDICAL  GYNECOLOGY. 

be  permitted  to  stand  or  walk  too  long  at  a  time,  and  she 
should  assume  the  recumbent  position,  either  upon  the  back 
or  either  side,  whichever  gives  her  the  most  relief.  Some- 
times the  homemade,  well-fitting  abdominal  supporter  gives 
a  certain  amount  of  relief  in  large  fibroids.  The  menorrhagia 
is  to  be  controlled  by  ergot  and  hydrastis  canadensis,  either 
or  both.  The  object  in  giving  the  ergot  is  to  produce  uterine 
contractions,  and  so  lessen  the  circulation,  and  at  the  same 
time  favor  the  natural  cure  of  fibroids.  The  natural  tendency 
of  these  fibroid  growths  is  to  be  expelled  from  the  uterine 
wall  in  which  they  are  developed,  either  outward  or  inward — 
i.  e.,  they  are  gradually  forced  into  the  uterine  cavity,  or 
else  outward  toward  the  abdominal  cavity  beneath  the  peri- 
tonaeum. 

Ergot  has  the  most  marked  effect  in  controlling  the 
menorrhagia  in  those  cases  in  which  the  tumor  inclines 
toward  the  cavity  of  the  uterus.  A  number  of  preparations 
of  ergot  have  been  recommended.  I  have  never  found  any- 
thing better  than  the  fluid  extract,  when  prepared  by  such 
reliable  pharmacists  as  Dr.  Squibb.  It  has  been  used  by  the 
mouth  and  also  by  hypodermic  injection.  At  one  time  the 
hypodermic  method  was  fashionable,  and  it  was  then  believed 
to  be  the  most  efficient.  I  am  satisfied  in  my  own  mind  that 
it  has  no  advantages  over  its  administration  by  the  stomach, 
except  perhaps  that  in  a  large  fibroid,  and  during  the  period 
of  active  haemorrhage,  the  hypodermic  will  act  more  promptly 
and  more  efficaciously  in  the  way  of  producing  contractions, 
and  consequently  lessen  the  bleeding. 

The  great  objection  to  ergot  is  that  it  is  not  well  borne  by 
the  stomach  in  many  cases,  and  that  it  is  disagreeable  to  the 
taste  ;  and  yet  this  can  usually  be  overcome  by  combining  it 
with  pleasant  aromatics.  Again,  if  long  continued,  it  pro- 
duces deleterious  effects  upon  the  blood-vessels  elsewhere 
than  in  the  uterus,  and  so  it  should  not  be  given  for  a  long 
time.  This  has  driven  me,  of  late  years,  to  use  hydrastis 
canadensis,  the  aqueous  fiuid  extract.  It  appears  to  have 
nearly  as  much  control  over  the  haemorrhage  as  ergot ;  and 


THE   UTERINE  FIBROMATA.  361 

as  it  can  be  continued  for  an  indefinite  length  of  time  and  in 
large  doses,  is,  on  the  whole,  the  preferable  remedy.  It  is 
not  an  agreeable  preparation,  given  in  the  fluid  extract,  and 
so  that  has  caused  many  to  use  the  solid  extract,  or  the  ac- 
tive principle,  hydrastine.  Neither  of  these  are  as  efficient 
as  the  aqueous  fluid  extract,  and  by  combining  this  prepara- 
tion with  aromatics,  such  as  tincture  of  cardamom  or  cinna- 
mon water,  it  can  usually  be  taken,  and  it  has  this  advantage, 
that  it  nearly  always  agrees  with  the  stomach.  I  have  found 
some  patients  that  after  a  time  objected  to  it,  and  so  I  have 
used  the  fluid  extract  by  the  rectum,  ten  to  fifteen  drops, 
three  times  a  day.  Some  are  very  sensitive  to  its  action, 
and  have  pelvic  pain  if  it  is  given  in  large  doses  long  con- 
tinued. Whenever  this  pain  appears  and  is  clearly  trace- 
able to  this  agent,  the  dose,  of  course,  should  be  diminished. 

Iodide  of  calcium  is  a  remedy  that  has  been  highly  spoken 
of  in  the  treatment  of  fibroids.  Two  or  three  grains  three 
times  a  day,  given  in  water  half  an  hour  before  meals,  is  said 
to  have  decided  effect  in  controlling  the  growth  of  fibroids. 
This  has  led  me  to  adopt  the  following  plan  :  For  a  few  days 
before  the  menstrual  flow,  during  it,  and  for  a  few  days  after 
it  subsides,  I  use  the  hydrastis  ;  in  the  interval  I  use  the 
iodide  of  calcium. 

It  occasionally  happens  that  the  menorrhagia  is  extremely 
great  and  does  not  yield  to  the  treatment  employed.  The  pa- 
tient becomes  so  reduced  that  heart  stimulants,  such  as  digi- 
talis and  nux  vomica,  are  necessary.  In  such  instances  com- 
plete rest  should  be  insisted  upon  during  the  flow,  and  some 
relief  is  often  obtained  by  using  a  warm  (not  hot)  vaginal 
douche  of  acetic  acid  in  solution.  I  use  from  two  to  four 
quarts  of  water,  with  an  ounce  of  good  cider  vinegar  to  each 
quart.  If  this  causes  any  smarting  pain  the  quantity  of  vine- 
gar can  be  reduced.  As  a  matter  of  course,  every  means 
should  be  employed  to  maintain  the  health  of  the  patient  as 
near  to  the  normal  standard  as  possible,  so  that  she  may  be 
the  better  able  to  bear  her  burden. 


CHAPTER  XXIX. 

Maligxaxt  disease  of  the  uterus,  ovaries,  and  mammse 
frequently  comes  under  the  observation  of  the  gynecologist ; 
and  although  up  to  the  present  time  surgical  treatment  has 
been  almost  exclusively  adopted  as  the  only  means  of  battling 
with  this  form  of  disease,  there  are,  however,  certain  points 
in  the  management  of  cancer  which  belong  to  the  domain  of 
medicine.  All  that  pertains  to  the  jDrevention  of  cancer,  in 
so  far  as  it  is  inherited  or  acquired  by  certain  conditions,  and 
the  treatment  in  the  earlier  stages,  come  under  the  care  of 
the  physician. 

In  recent  times  pathologists  have  favored  the  idea  that 
cancer  is  dependent  upon  a  certain  germ.  When  this  comes 
to  be  better  understood,  it  is  possible  that  medical  treatment 
may  be  sufficient  to  prevent  or  to  cure  this  affection.  But  at 
the  present  time  our  knowledge  of  the  disease  appears  to  be 
limited  to  the  fact  that  certain  organizations  are  predisposed 
to  cancer  disease ;  and  if  it  should  be  found  in  the  future 
that  the  disease  is  due  to  a  cancer  germ,  the  fact  will  still 
remain  that,  in  order  that  this  germ  may  be  effective  in  pro- 
ducing cancer,  a  certain  kind  of  organization  or  a  certain 
quality  of  tissue  is  favorable  to  the  action  of  this  germ.  It  is 
known  that  the  tubercular  bacilli  (and  the  germ  of  cancer  if 
there  is  one)  require  a  certain  kind  of  tissue  to  live  upon, 
hence  some  enjoy  an  immunity  from  these  maladies,  while 
others  are  predisposed  to  them. 

Some  of  the  diseases  due  to  specific  germs  attack  all  alike, 
the  strong  and  the  weak — typhoid  fever,  for  example.     It  is 

363 


CANCER.  363 

very  different  with  sucli  diseases  as  cancer.  Those  germs 
that  require  special  tissue  to  live  upon  act  locally.  The 
other  germs  that  attack  all  organizations  are  general  in  their 
action. 

There  are  certain  things  that  we  know  now  which  obtain 
almost  invariably  in  cases  that  develop  cancer  —  such,  for 
example,  as  the  fact,  pointed  out  long  ago  by  Virchow,  that 
the  pulmonary  artery  is  abnormally  small  in  those  who  die  of 
cancer.  I  have  kept  a  record  of  a  very  large  number  of  cases 
of  cancer  of  the  uterus,  mammary  glands,  and  ovaries,  and  I 
think  I  can  say  that,  without  exception,  I  have  found  the  pul- 
monary circulation  defective,  and  consequently  respiration 
and  blood  aeration  insufficient  to  a  certain  degree. 

The  vast  majority  of  subjects,  also,  have  been  stout,  with 
a  preponderance  of  adipose  and  cellular  tissue.  In  fact,  they 
have  been  somewhat  chlorotic  as  a  rule,  and  of  the  lym- 
phatic temperament.  In  short,  while  digestion  and  assimila- 
tion have  been  normal,  disassimilation,  disintegration,  and 
elimination  have  been  imperfect  or  sluggish.  It  would  seem, 
therefore,  that  this  condition  of  organization  predisposed  to 
malignant  disease  ;  and  if  such  is  the  fact,  then  much  can  be 
done  in  the  way  of  development  and  general  management  in 
early  life  to  overcome  this  peculiar  tendency  to  disease.  All 
that  was  said  in  discussing  the  management  of  chlorotic  and 
phlegmatic  girls  would  apply  with  equal  force  to  the  preven- 
tion of  cancer.  I  need  not,  then,  in  this  connection,  dwell 
upon  that  part  of  the  subject. 

The  condition  of  the  organization  at,  toward,  or  immedi- 
ately after  the  menopause — the  time  at  which  malignant  dis- 
ease usually  shows  itself — will  now  be  considered.  I  am 
quite  confident  that  at  this  time  much  can  be  done  to  prevent 
the  appearance  of  cancer  by  improving  the  general  health 
and  the  condition  of  the  tissues. 

The  diagnosis  of  this  condition  is  based  upon  the  special 
temperament,  usually  phlegmatic,  somewhat  chlorotic,  it  may 
be,  with  small  circulatory  apparatus,  at  any  rate  so  far  as  the 
pulmonary  artery  is  concerned,  and  hence  the  imperfect  res- 

24 


364:  MEDICAL  GYNECOLOGY. 

piration  and  blood  aeration  referred  to,  the  superabundance 
of  adipose  and  cellular  tissue,  as  shown  by  the  general  ap- 
pearance of  the  patient,  with  sluggish  excretion  or  elimina- 
tion, indicated  chiefly  by  renal  and  hepatic  torpor.  These 
conditions  of  ultimate  nutrition  are  very  often  spoken  of  as 
lithsemia,  and  hence  I  might  say  that  lithgemic  patients  at  this 
period  of  life  are  predisposed  to  cancer. 

It  will  be  seen  that  this  condition  may  be  largely  due  to 
inherited  temperament  and  general  organization,  and  yet  to  a 
large  extent  it  may  be  acquired.  Some  of  the  modifications 
of  nutrition  which  have  been  referred  to  in  discussing  the 
menopause  clearly  eventuate  in  this  predisposition  to  malig- 
nant disease. 

Dr.  Arthur  W.  Johnston  (in  whose  opinion  I  have  pro- 
found confidence)  believes  that  the  chief  cause  of  carcinoma 
is  failure  of  the  trophic  nerves,  the  failure  being  brought 
about  by  some  nerve  strain  or  great  sorrow.  I  accept  without 
hesitation  the  theory  regarding  the  causative  relation  of  the 
trophic  nerves  to  cancer,  but  my  clinical  experience  makes 
me  doubt  if  nerve  strain  is  the  primary  cause.  I  incline  to 
the  opinion  that  failure  of  the  trophic  nerves  occurs  more 
readily  in  those  organizations  which  I  have  described  as  pre- 
disposed to  malignant  disease.  But  whether  the  nerve  strain 
is  a  necessary  element  in  the  causation  of  cancer  or  not,  the 
trophic  nerves,  which  preside  over  all  tissue  changes,  cer- 
tainly play  an  important  part  in  the  aetiology  of  cancer,  and 
have  a  certain  bearing  on  the  question  of  treatment. 

Treatment. — The  indications  in  this  condition  are  to  im- 
prove the  character  of  the  tissues,  first  by  diet,  and  then  by 
every  possible  means  which  can  favor  ultimate  nutrition  by 
promoting  the  depleting  processes,  or  disintegration  and 
elimination. 

In  regard  to  the  matter  of  diet,  I  am  confident  that  all  the 
articles  of  food  and  drink  which  retard  tissue  waste  or  elimi- 
nation of  worn-out  tissues,  such  as  alcohol  (especially  in  the 
form  of  beer),  tea,  and  coffee,  should  be  avoided.  Certain 
observations  that  I  have  made  lead  to  the  conclusion  that 


CANCER.  365 

beer-drinking  people,  and  to  a  less  extent  wine-drinkers,  are 
more  subject  to  cancer.  This  is  an  additional  reason  for  my 
urging  the  restricted  use  of  such  articles  through  life,  and 
especially  at  the  time  when  cancer  is  likely  to  appear.  The 
excessive  use  of  animal  food,  while  it  may  not  in  itself  pre- 
dispose to  malignant  disease,  does  so  when  it  is  used  in  ex- 
cess in  connection  with  alcohol ;  and  those  who  take  spar- 
ingly of  animal  food,  I  find,  can  bear  a  larger  amount  of 
alcohol  with  less  injurious  effects.  And  so,  in  a  given  case, 
if  I  found  that  they  took  animal  food  sparingly,  but  alcohol 
in  considerable  quantity,  I  should  continue  the  alcohol  but 
diminish  the  quantity.  It  is,  I  presume,  on  account  of  this 
effect  of  animal  food  and  alcohol  in  producing  a  tendency  to 
cancer  that  milk  diet  has  obtained  a  considerable  reputation 
in  the  management  of  malignant  disease. 

Next  to  diet,  every  means  should  be  employed  to  regulate 
the  renewal  of  tissue  ;  and,  first,  by  getting  clear  of  waste 
material.  Diet  having  been  properly  adjusted,  and  food 
given  in  quantities  that  can  be  easily  and  thoroughly  di- 
gested, will  insure  the  best  possible  supply  of  tissue.  Then 
if,  by  the  means  at  command,  free  disintegration  and  elimina^ 
tion  can  be  secured,  much  will  be  accomplished  toward  pre- 
venting the  appearance  of  cancer.  The  bowels  should  be  kept 
regular,  and  yet  not  unnecessarily  free.  The  kidneys  should 
be  made  to  do  their  whole  duty,  and  the  intestinal  secretions, 
including  hepatic  secretion,  should  be  carefully  looked  after. 
The  skin  also  requires  attention  ;  and  here  I  believe  the  Turk- 
ish bath  is  of  value,  especially  to  those  who  have  not  sufiicient 
exercise  to  induce  free,  healthful  perspiration.  A  Turkish 
bath  once  or  twice  a  week,  with  thorough  massage,  will  greatly 
improve  the  ultimate  nutrition.  Exercise  should  be  carefully 
regulated.  It  is  a  rare  thing  to  see  cancer  in  an  active  person 
who  does  not  carry  a  superabundance  of  adipose  tissue,  and 
who  takes  a  sufiicient  amount  of  muscular  exercise,  and  yet 
not  too  much.  If  diet,  exercise,  and  eliminating  agents  be  em- 
ployed to  excess,  so  that  the  renewal  of  tissue  is  insufficient, 
and  the  patient  becomes  debilitated  and  suffers  from  lack  of 


366  MEDICAL   GYXECOLOGY. 

nutritive  supply,  the  tendency  to  malignant  disease  will  be 
favored. 

Care  must  always  be  taken  not  to  overdo  the  eliminating 
process.  The  balance  between  waste  and  repair  should  be 
maintained  as  nearly  perfect  as  possible,  the  great  object  be- 
ing to  secure  complete  ultimate  nutrition,  so  that  the  tissues 
may  not  become  too  old  and  worn  out  before  they  are  broken 
down  and  thrown  off.  I  am  not  sure  that  I  will  be  thoroughly 
understood  when  I  speak  of  old  tissues,  but  I  apply  the  term 
to  a  condition  in  which  the  process  of  waste  and  repair  is  re- 
tarded, and  the  tissues  are  not  broken  dovm  and  thrown  off 
after  they  have  served  their  purpose.  That  is  what  I  mean, 
and  that  is  the  condition  which  I  believe  favors  the  appear- 
ance of  cancer,  and  the  chief  thing  to  be  overcome  by  treat- 
ment directed  to  prevent  it.  Dr.  Johnston's  views  regarding 
causation  suggest  the  necessity  for  the  use  of  agents  that 
may  improve  the  condition  of  the  nervous  system.  This,  of 
course,  is  largely  accomplished  through  im^Drovement  of  the 
general  nutrition,  but  nerve  tonics,  and  sedatives  if  needed, 
should  be  employed. 

This  leads  up  to  the  consideration  of  medicinal  agents 
which  are  supposed  to  have  some  influence  on  the  ultimate 
nutrition,  and  which  have  been  used  in  the  past,  in  the  hope 
of  preventing  cancer  or  of  arresting  its  progress  when  it  has 
manifested  itself  in  any  location. 

A  number  of  remedies  have  been  employed  in  the  past, 
and  we  may  say  of  most  of  them  that  they  have  been  weighed 
in  the  balance  and  found  wanting.  At  one  time  condurango, 
Chian  turpentine,  and  several  others,  have  been  lauded  for 
their  curative  power  in  cancer,  but  they  have  been  found,  if 
not  useless,  almost  so.  Those  that  are  used  most  at  the  pres- 
ent day,  and  which  still  claim  some  confidence,  are  prepared 
chalk  and  arsenic. 

In  regard  to  the  chalk,  which  was  first  used  in  the  form  of 
calcined  oyster  shells,  given  in  powders,  ten  to  twenty  grains, 
three  times  a  day,  there  were  several  theories  regarding  its 
action,  but  whether  they  were  correct  or  not  is  unknown. 


CANCER.  367 

From  personal  experience  I  am  unable  to  say  that  this 
agent  is  reliable.  As  it  is  a  harmless  article,  I  can  see  no 
objection  to  using  it ;  but  I  would  rely  far  more  upon  arsenic. 
Arsenic  has  a  decided  influence  upon  ultimate  nutrition,  espe- 
cially of  the  skin  and  mucous  membranes  ;  and  as  cancer  usu- 
ally makes  its  appearance  in  those  tissues,  anything  that  can 
improve  their  nutrition  must  be  of  some  benefit.  Such  is  the 
fact,  based  upon  the  therapeutic  action  of  arsenic,  and  the 
same  thijig  is  observed  clinically.  On  this  account  I  have 
employed  this  remedy  in  the  management  of  the  conditions 
which  I  believe  predispose  to  cancer  and  in  cases  where  can- 
cer actually  had  appeared,  and  with  benefit.  On  the  same 
principle  I  have  employed  mercury  and  iodine,  a  favorite 
prescription  being  small  doses  of  chloride  of  mercury  with 
arsenic,  continued  for  a  time  and  then  changed  for  iodine 
and  arsenic.  Small  doses  of  the  latter,  and  also  of  the  mer- 
cury, should  be  employed,  as  it  is  a  long-continued  action 
which  gives  the  result. 

These  are  the  remedies  that  at  the  present  time  are  most 
efficacious,  and  I  believe  that  if  persistently  continued,  and 
if  begun  early  in  the  course  of  the  disease,  but  more  espe- 
cially if  employed  when  there  is  an  apparent  tendency  to 
the  disease,  they  are  potential  preventives— at  any  rate,  the 
best  there  are.  When  cancer  is  present,  I  need  hardly  say 
that  surgical  treatment  is  indicated,  and  is  the  only  treat- 
ment that  promises  any  relief. 

Within  the  past  few  years  much  has  been  said  with  refer- 
ence to  the  eifect  of  pyoctanin,  an  aniline  preparation.  This, 
I  am  satisfied,  is  of  some  value  in  arresting  the  progress  of 
the  disease  when  applied  locally,  but  this  belongs  to  the  do- 
main of  surgery.  What  effect  it  may  have  when  given  inter- 
nally is  not  decided. 

A  word  may  be  said  regarding  the  treatment  of  cancer  by 
local  applications  in  the  way  of  plasters  and  caustics,  and  so 
on.  This,  of  course,  is  surgical  treatment,  and  the  most  bar- 
barous kind  of  surgery,  and  so  nothing  further  need  be  said 
on  that  subject. 


368  MEDICAL  GYNECOLOGY. 

It  sometimes  .happens  that,  after  the  surgeon  has  done  his 
best  for  the  relief  of  malignant  disease,  his  efforts  fail,  and 
the  patient  falls  into  the  hands  of  the  physician  in  her  last 
days.  There  is  only  one  word  to  say  on  that  subject.  Under 
these  circumstances  the  physician's  first  and  only  duty  is  to 
give  relief  and  add  to  the  comfort  of  the  patient  as  far  as  pos- 
sible. Opium  is  the  agent  which  alone  can  do  this,  and  I  be- 
lieve in  the  free  use  of  it  in  the  management  of  such  cases, 
doses  sufficient  to  relieve  jmin.  I  may  add  that  I  believe 
that  not  only  does  opium  relieve  pain  in  cancer,  but  it 
retards  the  progress  of  the  disease.  I  have  an  idea  which 
I  hardly  dare  express,  and  that  is,  that  the  habitual  use 
of  opium  prevents  cancer  to  a  limited  extent.  If  that  is 
a  fact,  then  the  use  of  opium  in  the  treatment  of  cancer  cer- 
tainly accomplishes  what  I  have  long  thought  it  did,  and 
that  is,  to  retard  the  progress  of  the  disease. 

All  that  has  been  said  in  this  connection  applies  equally 
to  cancer  of  the  uterus,  ovaries,  or  mammary  glands,  which 
covers  the  whole  field  of  the  gynecologist. 


CHAPTER  XXX. 

UNNATURAL    HABITS. 

The  Invalid  Habit. — A  singular  perversion  of  life,  mental 
and  physical,  is  seen  among  women  who  insist  upon  being 
invalids  while  there  is  nothing  discoverable  the  matter  with 
them.  They  constitute  a  class  very  distinct  from  hysteria, 
neurasthenia,  and  fancied  ailments  such  as  have  been  alluded 
to  under  the  head  of  introspection. 

Those  who  have  too  much  time  and  money  and  few  in- 
terests in  the  world  are  the  most  predisposed  to  this  affec- 
tion. Disappointed  maids  and  "spoiled"  wives  form  the 
largest  number. 

They  complain  either  of  strange  nerve  symptoms  or  ob- 
scure pelvic  pains,  which  incapacitate  them  for  any  kind  of 
mental  or  physical  work.  The  diagnosis  is  difScult,  owing  to 
the  fact  that  they  have  learned  how  to  give  minute  descrip- 
tions of  certain  symptoms  which  they  imagine  they  have.  As 
a  rule  they  have  suffered  from  some  real  affection  which  they 
cling  to  long  after 'recovery.  The  only  derangement  usually 
found  is  the  lax,  soft  tissues  which  come  from  disuse.  The 
nerves  ache  and  the  muscles  also,  when  called  upon  to  act, 
and  the  suffering  which  follows  any  effort  gives  an  excuse 
for  persisting  in  inactivity.  In  time,  by  careful  exclusion, 
frequent  examinations  and  careful  watching,  the  diagnosis 
can  be  definitely  made.  The  causes  are  twofold — either  over- 
treatment  of  slight  affections  of  the  pelvic  organs,  or  un- 
suitable treatment  of  trivial  affections  of  the  nutritive  and 
nervous  systems.  All  the  cases  that  I  have  seen  have  begun 
with  some  uterine  or  ovarian  disease,  for  which  they  have 

369 


370  MEDICAL  GYNECOLOGY. 

been  "treated  to  death,"  as  the  common  saying  goes.  Owing 
to  the  oversupply  of  medical  men  in  this  country,  there  are 
to  be  found  those  who  are  ready  to  indulge  patients  in  the 
dissiiDation  of  invalidism  ;  this  leads  up  to  incurable  imagi- 
nary ills. 

The  rest-cure,  with  forced  feeding,  so  often  employed  in 
cases  that  do  not  require  it,  is  responsible  for  many  ex- 
amples of  the  invalid  habit.  In  many  cases  that  I  have 
seen— hysteria,  nervous  exhaustion,  and  neurasthenia— pa- 
tients have  undergone  this  plan  of  treatment  and  come 
out  of  it  fat,  full-blooded,  but  more  helpless  and  useless 
than  before  undertaking  treatment  at  all. 

Treatment. — Such  patients,  having  been  long  treated  as 
invalids,  do  not  like  to  be  told  the  truth — that  there  is 
nothing  the  matter  with  them.  Some  cases  that  I  have  seen 
have  come  from  perfectly  honest,  capable  practitioners,  who 
have  told  them  that  they  did  not  require  treatment.  This 
disappoints  them  and  they  seek  other  aid.  I  have  found  it 
necessary  to  put  them  under  training  after  having  gained 
their  confidence,  not  by  deceiving,  but  by  taking  sufficient 
interest  in  their  troubles  to  show  them  the  true  nature  of 
their  condition.  It  is  well,  if  possible,  to  convince  such 
that  the  real  trouble  is  the  invalid  habit  which  has  to  be 
broken  up  by  proper  treatment.  Those  who  from  long-con- 
tinued mental  depression  and  inactivity  suffer  from  mal- 
nutrition and  neuralgic  pain,  real  as  well  as  imaginary,  re- 
quire general  treatment,  but  such  sufferers  and  those  who  are 
as  well  nourished  as  they"  can  be  under  the  circumstances  re- 
quire systematic,  gradually  increasing  mental  and  j)hysical 
exercise.  Active  exercise  is  that  which  is  required.  Massage 
is  to-day  too  often  used  in  such  cases,  for  it  is  worse  than 
useless  in  the  condition  under  consideration.  Massage  and 
passive  exercise  are  useful  to  improve  nutrition  and  retain 
strength  for  a  time,  but  the  effect  is  limited.  The  nerve  force 
and  muscular  power  can  only  be  restored  by  one's  own  efforts. 
Massage  and  rubbing  aid  in  obtaining  rest  and  restoration, 
but  can  not  do  what  voluntary  exercise  does.     Many  of  the 


UNNATURAL  HABITS.  371 

worst  cases  tliat  have  come  under  my  observation  have  had 
the  rest-cure  (including  massage,  electricity,  and  all  that  an 
attendant  can  do  for  a  patient)  without  relief. 

The  invalid  habit  should  be  treated  with  the  "occupation 
and  exercise  cure."  This  should  be  regulated  with  great 
care,  the  rule  being  to  find  out  how  much  the  mind  and  body 
can  do  without  fatigue.  The  limit  of  endurance  should  be 
found.  This  is  very  difficult,  owing  to  the  fact  that  the 
patient's  .judgment,  being  perverted,  can  not  be  depended 
upon,  at  the  beginning  of  the  treatment  at  least.  The  direc- 
tions must  be  given  to  the  nurse,  and  the  effects  noted  by  the 
physician. 

At  first,  mental  occupation  and  physical  exercise  suitable 
to  the  condition  should  be  taken  for  a  short  time;  in  bad 
cases  all  that  the  patient  can  be  induced  to  do  is  generally 
right.  The  moment  there  is  any  excitement  (indicating 
fatigue)  shown  by  the  pulse  or  in  breathing,  the  work 
should  be  stopped.  Rest  should  be  given  until  the  feeling 
of  fatigue  passes  off,  and  occupation  should  at  once  be  re- 
sumed. If  the  patient  is  not  disposed  to  rest,  and  if  she 
does  rest,  but  without  relief  from  fatigue,  the  exercise  and 
occupation  have  been  too  long  continued  and  the  next  effort 
should  be  shorter.  The  mental  exercise  should  consist  in 
reading  or  having  some  one  read  to  the  patient,  for  a  very 
short  time  at  first  and  at  several  stated  times  each  day, 
and  in  conversation  with  intelligent  friends  or  attendants  on 
any  subject  of  interest  not  connected  with  the  patient's  own 
condition.  Gymnastic  exercise  should  be  taken,  at  first  in 
the  reclining  position,  according  to  the  method  described 
under  the  head  of  muscular  exercise  in  general  therapeutics. 

The  Opium  Habit. — This  subject  is  taken  up  here  for  several 
very  good  reasons.  In  the  practice  of  gynecology  one  sees  as 
many,  perhaps  more,  cases  of  the  opium  habit  as  in  any 
other  branch  of  medicine,  and — I  say  it  reluctantly — gyne- 
cologists are  responsible  for  making  opium  TiabituSs  occa- 
sionally. A  volume  could  easily  be  filled  with  the  history  of 
cases  of  dysmenorrhoea  and  pelvic  inflammations  that  have 


372  MEDICAL  GYNECOLOGY. 

been  treated  with  opium  until  the  habit  has  been  established. 
The  blame  has  too  often  been  laid  at  the  door  of  general  prac- 
titioners. They  have  been  charged  with  giving  opium  to  re- 
lieve pain  and  suffering,  when  appropriate  treatment  would 
have  been  sufficient  without  the  narcotic.  Though  there 
may  be  some  justice  as  well  as  truth  in  this,  I  know  that 
gynecologists  have  as  much,  or  more,  to  answer  for  in  this 
respect  as  the  general  practitioner. 

I  have  found  that  opium  after  operations  is  often  so 
freely  given  and  its  use  so  long  continued  that  the  habit  is 
fixed  and  kept  up  after  the  patient  is  dismissed  as  cured. 
In  my  own  practice  I  find  it  necessary  to  employ  ojjium 
in  the  treatment  of  painful  affections  and  after  certain  op- 
erations ;  and  it  is  often  difficult  to  wean  patients  from  the 
influence  of  the  drug  after  the  need  for  it  is  gone ;  but  I 
invariably  see  to  it  that  the  use  of  opium  is  given  up  before 
the  case  is  permitted  to  pass  from  under  observation.  If  this 
rule  were  observed,  and  if  greater  care  were  excercised  by 
doctors  in  the  use  of  opium,  there  would  be  fewer  habitues. 
There  are  women  who  use  opium  without  any  excuse  in  the 
way  of  physical  suffering,  but  the  fact  remains,  as  I  have 
stated  it,  that  doctors  of  medicine  have  been  in  the  past 
guilty  to  a  large  degree,  though  without  intent. 

The  great  object  of  the  physician  should  be  to  use  opium 
with  the  idea  constantly  in  his  mind  that  it  is  a  dangerous 
thing,  and  if  he  requires  to  employ  it  for  a  long  time  in  any 
case  he  should  see  that  it  is  given  up  before  dismissing  such 
patients.  If  he  fails  in  this  he  is  responsible.  The  effect  of 
opium  on  the  sexual  organs  in  women  is  peculiar  and  dis- 
tinct ;  and  this  must  be  clearly  understood  before  one  can 
comprehend  how  easy  it  is  for  women  to  acquire  the  habit 
and  how  hard  it  is  for  them  to  abandon  it. 

It  has  been  claimed  that  the  difficulty  in  curing  women  of 
the  opium  habit  was  wholly  due  to  their  inferior  will  power. 
This  I  am  sure  is  a  grave  error.  Women  bear  pain  and  suf- 
fering better,  and  are  more  capable  of  self-denial  in  many 
respects,  than  men  ;  and  hence  they  would  be  easier  to  cure 


UNNATURAL   HABITS.  3^3 

were  it  not  for  the  fact  that  they  suffer  from  many  more  dis- 
eases of  their  sexual  organs  which  require  opium  for  their 
treatment.  It  is  thus  most  difficult  to  tell  when  the  neces- 
sity for  opium  arising  from  physical  suffering  is  present  or 
absent. 

The  chief  effects  of  opium  on  the  sexual  organs  are,  first, 
to  quiet  nervous  irritability  and  hypersesthesia ;  next,  to 
relieve  congestion. 

Opiuno,  as  is  readily  known,  is  the  most  available  remedy 
to  control  the  initial  stage  of  acute  inflammation,  and  also  to 
relieve  the  suffering  in  chronic  inflammations.  So  long,  then, 
as  there  is  any  inflammatory  condition  of  the  pelvic  organs, 
there  are  indications  for  the  use  of  opium.  In  that  functional 
derangement — excessive  sexual  appetence — opium  in  large 
and  continued  doses  gives  far  more  and  certain  relief  than 
the  bromides.  This  I  know  from  clinical  experience.  I  have 
the  testimony  of  one  of  the  most  perfect  types  of  women — 
mentally,  physically,  and  morally — that  I  have  ever  seen. 
Her  flne  mind  was  cultivated  to  the  highest  degree  ;  but, 
owing  to  circumstances  in  early  life,  her  sexual  proclivities 
wer^  developed  to  an  extraordinary  degree,  and  she  was 
obliged  to  live  a  single  life.  On  one  occasion,  when  she  was 
suffering  an  unusual  amount  of  physiological  pelvic  conges- 
tion, her  physician  gave  her  a  dose  of  opium.  This  produced 
relief,  first  by  quieting  her  nervous  system  so  that  she  could 
endure  physical  discomfort,  and,  secondly,  by  quelling  pelvic 
congestion  and  sexual  hypersesthesia.  This  was  the  begin- 
ning of  a  course  which  in  a  short  time  ended  in  the  "  drug 
habit." 

While  she  continued  her  opium  she  was  absolutely  free 
from  unsatisfied  sexual  craving,  yet  knew  full  well  that  opium 
was  objectionable  ;  but  felt  as  if  it  improved  her  so  much,  mor- 
ally as  well  as  physically,  that  she  continued  it. 

Later,  when  she  came  under  my  care,  I  learned  that  much 
of  her  history.  She  told  me,  too,  that  all  other  narcotics  had 
been  tried  in  hopes  that  opium  could  be  given  up,  but  that 
they  all  rather  aggravated  than  calmed  her  sexual  disturb- 


374  MEDICAL  GYNECOLOGY. 

ances.  There  was,  however,  one  exception.  Very  large  doses 
of  bromide  and  camphor  helped  her ;  but  the  doses  needed 
could  not  be  borne,  because  they  gave  rise  to  constitutional 
disturbances  that  were  quite  alarming.  The  evidence  from 
such  an  intelligent  and  highly  moral  patient  enabled  me  to 
place  the  proper  value  upon  like  testimony  which  I  had  often 
obtained  from  others. 

After  improving  this  lady's  general  health  I  was  able  to 
help  her  to  give  up  the  habit.  She  remained  in  good  health, 
and  the  sexual  disturbances  did  not  reappear,  a  fortunate  cir- 
cumstance which  I  least  exjDected, 

Another  effect  of  this  drug  is  to  induce  amenorrhoea.  I 
have  seen  the  menses,  absent  five  and  a  half  years,  return 
vvdthin  a  month  after  total  abandonment  of  the  morphine 
habit,  with  the  duration  and  amount  of  flow  that  mark  the 
menstruation  of  a  healthy  young  girl.  Amenorrhoea  is 
brought  about  by  the  influence  of  the  drug  upon  both  inner- 
vation and  circulation.  In  disease  it  diminishes  the  inflam- 
matory condition,  and  in  health  so  lowers  tone  that  the  nor- 
mal functions  are  suspended. 

I  have  had  an  opportunity  of  examining  a  large  number  of 
Tiahitues,  some  in  my  own  practice,  others  sent  to  me  by  Dr. 
Matteson — the  highest  authority  in  this  country  on  treatment 
of  the  drug  habits — and  in  all  of  them  I  have  found  that  the 
physical  condition  corresponded  to  the  modification  of  func- 
tion. All  the  pelvic  organs  and  tissues  were  anaemic  and  in  a 
state  of  malnutrition — a  condition  somewhat  resembling  that 
occurring  after  the  menopause.  Hence  it  may  readily  be  seen 
that  the  first  step  is  to  make  sure  there  are  no  diseases  of  the 
pelvic  organs  which  actually  require  attention  before  aban- 
doning the  drug. 

To  make  a  diagnosis  is  exceedingly  difficult,  because  the 
testimony  of  the  patients  is  unreliable.  They  have  pain  when 
the  opium  is  withdrawn,  or  when  it  is  "time  to  have  the 
drug" — and  local  pain  at  that;  hence  the  point  is  to  deter- 
mine whether  this  is  the  call  of  a  craving  nerve  or  a  pain  due 
to  an  actual  morbid  state.     The  physical  signs  obtained  by 


UNNATURAL  HABITS.  375 

temperature,  touch,  and  inspection  are  the  only  things  to  rely 
upon.  The  temperature  rises  when  the  drug  is  withdrawn 
and  falls  when  it  is  given  again.  I  have  seen  sudden  stop- 
page push  the  temperature  to  103*5°  F.,  and  this  fell  to  nor- 
mal promptly  when  a  dose  of  opium  was  given.  Severe  neu- 
ralgic pain  accompanies  this  rise  of  temperature. 

In  no  disease  of  the  sexual  organs  is  there  such  tempera- 
ture variation  as  occurs  in  withholding  opium  and  giving  it 
again  to  its  liabitues ;  hence  the  value  of  the  clinical  ther- 
mometer in  making  a  diagnosis. 

The  treatment  of  the  opium  habit  is  difficult  to  carry  out 
in  private  practice.  I  am  so  fully  satisfied  of  that  fact  that 
I  hope  the  time  will  come  when  this  and  the  alcohol  and 
cocaine  habits  will  be  considered  as  a  mental  aberration,  Jus- 
tifying commitment  to  an  institution  for  treatment.  This 
seems  to  be  especially  necessary  in  this  country,  for  our 
Western  races  do  not  use  opium  as  the  Orientals  do.  When 
the  former  once  begin  they  go  on  from  bad  to  worse,  having 
no  power  to  keep  from  increasing  the  quantity.  To  send 
these  cases  to  institutions  for  treatment  is  the  proper  thing, 
but  the  physician  finds  this  impracticable  in  all  cases  ;  there- 
fore he  should  be  prepared  to  do  the  best  under  the  circum- 
stances. Those  who  have  not  lost  all  sense  of  right  and  will 
power,  who  strongly  desire  to  recover,  can  be  managed  at 
home ;  but  it  is  most  difficult  to  discover  those  cases.  Nearly 
all  profess  a  desire  to  give  up  the  drug,  but  it  is  an  insincere 
profession,  and  shows  itself  in  its  true  colors  when  the  dose 
is  reduced  until  it  fails  to  satisfy  the  craving. 

Having  determined  that  there  is  no  condition  of  the  pelvic 
organs  causing  pain  and  necessitating  the  use  of  opium,  the 
next  thing  is  to  obtain  perfect  control  of  the  patient  and  her 
supply  of  opium.  This  can  be  done  most  easily  by  placing 
her  in  an  institution  ;  but  this  is  not  at  all  times  possible,  as 
already  stated.  The  next  best  thing  is  to  obtain  an  attend- 
ant or  nurse  who  can  be  relied  upon  to  honestly  follow  out 
the  directions,  which  is  often  the  most  diflicult  of  all.  Rela- 
tions, friends,  and  sometimes  nurses  will  be  deceived  or  per- 


376  MEDICAL  GYNECOLOGY. 

mit  themselves  to  yield  to  the  wishes  of  the  patient,  whose 
cunning,  cleverness,  and  lack  of  moral  sense  often  enables  her 
to  demoralize  the  attendants. 

There  are  two  methods  of  giving  up  the  use  of  the  drug : 
one  the  abrupt  or  immediate,  and  the  other  the  gradual.  The 
latter  I  believe  to  be  the  only  rational  and  safe  method. 
Having  decided  upon  the  quantity  to  be  taken  daily  by  the 
patient  and  the  size  and  frequency  of  the  dose  at  each  time, 
the  reduction  can  be  begun.  The  same  method  of  adminis- 
tration should  be  continued,  only  lessening  each  dose  a  very 
little,  but  in  a  definite  quantity.  The  amount  given  during 
the  day  should  be  reduced,  while  the  last  dose  at  night 
should  continue  the  same.  I  presume  that  if  it  has  been 
used  hypodermically,  that  method  of  administration  should 
be  employed,  but  in  diminishing  doses,  and  so  in  regard  to 
any  form  of  the  drug  and  way  of  giving  it. 

Changing  the  form  or  preparation  of  the  opium  is  highly 
spoken  of  by  some.  Dr.  Matteson  strongly  commends  the 
use  of  codeine  hypodermically  in  place  of  the  opium  or  mor- 
phine. 

The  general  nutrition  of  the  habitue  is  never  good  as  a 
rule,  and  is  likely  to  become  much  worse  when  the  quantity 
of  opium  is  reduced.  This  requires  that  every  effort  should 
be  made  to  improve  the  appetite  and  digestion.  During  the 
weaning  process  the  patient  becomes  extremely  nervous, 
restless,  and  sleepless.  Some  relief  from  these  symptoms  may 
be  obtained  by  large  doses  of  cannabis  Indica,  lupuline,  cam- 
phor, valerian,  and  that  class  of  remedies.  To  secure  sleep 
the  cannabis  Indica  is  the  best  of  the  above-named  drugs, 
though  the  coal-tar  products  are  also  of  use,  and,  when  they 
are  well  borne,  may  be  employed.  All  these  agents  are  only 
to  be  used  to  let  the  i^atient  down  more  easily,  just  as  stimu- 
lants and  coffee  contribute  to  the  relief  of  the  jDatient ;  but 
such  remedies  must  be  used  with  care  and  should  be  dimin- 
ished in  dose.  There  is  always  danger  of  changing  one  drug 
habit  for  another.  Reducing  the  dose  is  sometimes  rather 
easy,  but  the  giving  it  up  entirely  is  generally  a  hard  strug- 


UNNATURAL  HABITS.  3Y7 

gle.  When  the  drug  is  finally  abandoned,  the  patient  must 
still  be  watched  with  equal  care,  as  there  is  danger  of  relapse 
for  months  after  the  drug  is  wholly  given  up. 

Much  might  be  said  about  the  cocaine  and  alcohol  habits, 
but  the  management  of  such  cases  is  the  same  in  princiiDle  as 
in  opium  habitues.  I  may  say  that  the  alcohol  habit  is  sel- 
dom developed  from  the  suffering  incident  to  uterine  disease, 
and  in  this  respect  differs  greatly  from  the  opium  habit. 
Nearly  all.  the  cases  that  I  have  seen  of  the  alcohol  addic- 
tion came  from  heredity  or  perverted  social  life  common  to 
both  sexes. 


CHAPTER  XXXI. 

DISEASES   OF   THE   TJEIJSTAEY  ORGANS. 

The  majority  of  diseases  of  the  urinary  organs  are  of  sucli 
a  nature  that  they  require  surgical  treatment,  therefore  this 
whole  subject  has  been  included  in  the  domain  of  surgery. 
There  are,  however,  many  affections  which  naturally  come 
under  the  care  of  the  physician,  who  can  manage  them  with- 
out the  aid  of  surgery.  It  is  therefore  altogether  proper 
that  such  urethro-vesical  affections  should  be  treated  of  in 
this  work.  I  am  the  more  desirous  of  taking  up  the  sub- 
ject in  this  connection  since  I  have  frequently  observed,  that 
many  diseases  of  the  urethra  and  bladder  in  women  that  fall 
into  the  hands  of  the  gynecologist  are  subjected  to  local 
treatment  when  they  do  not  require  it — that  is  to  say,  in  a 
large  class  of  acute  and  functional  diseases  better  results  are 
obtained  by  medical  than  by  surgical  treatment. 

Function  of  the  Bladder. — In  discussing  this  subject,  it  is 
taken  for  granted  that  the  anatomy  of  the  urinary  organs  is 
understood.  A  word  or  two  only  will  be  given  regarding  the 
nerve  supply,  to  call  the  subject  to  mind. 

The  bladder  receives  its  nerve  supply  partly  from  the 
mesenteric  ganglia  of  the  sympathetic  and  partly  from  the 
lumbar  portion  of  the  spinal  cord.  It  has  therefore  nerve 
filaments  from  both  the  cerebro- spinal  and  sympathetic  sys- 
tems. The  sphincter  vesicae  is,  in  health,  in  a  state  of  tonic 
contraction  which  results  in  retaining  the  urine  in  the  blad- 
der. This  act  is  entirely  involuntary  and  unconscious,  and  is 
performed  in  a  perfect  manner  both  during  the  waking  and 
sleeping  hours.     When  it  is  desired  to  evacuate  the  bladder, 

378 


DISEASES  OF  THE  URINARY  ORGANS.  379 

this  sphincter  is  relaxed  by  an  act  of  the  will  conveyed 
through  the  cerebro- spinal  fibers  ;  but  this  relaxation  once 
accomplished,  the  further  act  by  which  the  organ  is  emptied 
is  performed  without  the  intervention  of  the  will.  The  ex- 
periments of  Kupressow  demonstrate  conclusively  that  the 
nerve  center  which  presides  over  contraction  and  relaxation 
of  the  sphincter  vesicae  is  located  in  the  lumbar  region  of  the 
spinal  cord ;  and  it  may  be  accepted  that  (with  other  func- 
tions of  a  protective  nature)  the  spinal  cord  maintains  the  nor- 
mal action  of  the  urinary  organ  in  this  respect. 

There  are  three  factors  in  the  functions  of  the  bladder: 
first,  the  process  by  which  it  is  filled  ;  next,  the  act  of  retain- 
ing the  urine  by  closure  of  the  neck  of  the  bladder  ;  and,  last- 
ly, evacuation.     These  will  be  considered  in  order. 

The  bladder  acts  as  a  reservoir  for  the  urine,  and  at  proper 
intervals  expels  it.  The  filling  of  the  organ  with  urine  is  a 
slow  and  gradual  process,  the  fluid  entering  it  from  the 
ureters  drop  by  drop,  or  in  a  very  small  stream.  As  it  en- 
larges it  does  so  in  the  direction  of  least  resistance — viz.,  later- 
ally and  superiorly.  The  lateral  being  its  longest  diameter, 
it  enlarges  first  in  that  direction,  until  after  a  time  a  limit  is 
set  by  the  bony  pelvic  boundaries,  when  it  rises  from  the  pel- 
vis somewhat,  thus  escaping  from  the  pressure  below.  This 
movement  of  the  bladder  is  facilitated  by  its  serous  surface 
gliding  easily  over  that  of  the  adjacent  organs. 

There  has  been  considerable  discussion  among  difierent 
authors  as  to  whether  closure  of  the  vesico-urethral  orifice  is 
a  voluntary  or  an  involuntary  act.  Witte  and  Rosenthal 
maintain  that  the  closure  is  due  to  "  tonicity  from  nerve  force," 
which  resists  the  urine  pressure.  Kupressow  holds  the  same 
view,  basing  his  opinion  on  a  series  of  experiments  which  he 
made,  and  further  maintains  that  the  sphincter  vesicae  is  at 
the  neck  of  the  bladder  to  eject  the  urine  completely  out  of 
the  urethra,  in  place  of  standing  guard  and  holding  the  vesi- 
cal outlet  closed.  By  others  it  is  claimed  that  this  musculo- 
elastic  ring  hinders  the  entrance  of  urine  into  the  urethra, 
but  that  the  tension  of  the  bladder  walls  when  the  organ  is 

25 


380  MEDICAL  GYNECOLOGY. 

filled  overbalances  this  elasticity,  and  a  drop  of  urine  escap- 
ing into  tlie  urethra  brings  the  necessity  for  the  urination  to 
the  senses,  and  the  act  then  becomes  a  voluntary  one. 

The  act  of  emptying  the  bladder  is  a  very  important  and 
interesting  process,  and  is  not  so  simj)le  as  raight  at  first  be 
imagined.  As  the  organ  has  three  openings  and  is  emptied 
by  the  concentric  contraction  of  its  muscular  coat,  there  is  dur- 
ing urination  a  tendency  to  regurgitation  or  backward  pressure 
of  the  fluid  into  the  ureters.  The  backward  flow  is  effectu- 
ally prevented  by  a  very  complete  and  interesting  arrange- 
ment. The  iDrotection  is  threefold :  First,  by  the  oblique 
direction  that  the  ureters  take  in  piercing  the  vesical  wall. 
Second,  by  the  two  muscular  sli]DS  that  pass  from  the  siDhinc- 
ter  vesicae  to  the  insertions  of  the  ureters.  As  the  bladder 
gradually  fills,  these  slips  are  tightly  drawn,  and  thus  par- 
tially or  wholly  close  the  ureteric  orifices. 

Moreover,  it  may  be  presumed  that  as  these  muscular  fas- 
ciculi have  their  origin  in  the  vesical  neck,  they  act  most  vig- 
orously during  urination,  when  the  bladder  i^ressure  tends  to 
cause  regurgitation  into  the  ureters.  Their  greatest  use  is,  in 
all  probability,  during  the  act  of  micturition.  This  view  is 
borne  out  by  the  fact  that  these  little  muscles  are  in  a  rudi- 
mentary condition  in  the  female,  the  urethra  being  shorter 
and  the  force  necessary  to  empty  the  bladder  much  less  than 
in  the  male ;  and,  further,  by  the  well-known  fact  that  when 
the  hypertrophy  of  the  muscular  walls  of  the  female  blad- 
der does  occur,  these  fasciculi  are  propoii;ionately  enlarged. 
Third,  by  a  ligamentous  band,  not  described  in  the  text- 
book^ of  anatomy,  which  runs  from  one  ureteric  opening  to 
the  other,  inclosing  their  vesical  ends,  and  known  as  the 
inter-ureteric  ligament.  Its  mode  of  action  is  this :  As  the 
bladder  gradually  fills,  the  oj)enings  of  the  ureters  are  car- 
ried farther  apart,  and  with  them  the  ends  of  the  ligament. 
Being  elastic,  it  yields  to  a  certain  extent,  and  after  a  time, 
being  able  to  yield  no  more,  pulls  upon  both  openings,  clos- 
ing them  more  or  less  completely.  During  urination  the  ten- 
sion of  the  ligament  gradually  decreases,  and  then  the  mus- 


DISEASES  OP  THE  URINARY  ORGANS.  381 

cular  fasciculi  and  the  oblique  direction  in  which  the  ureters 
enter  the  bladder  come  into  play,  the  ligament  being  of  use 
only  during  filling  and  distention. 

A  healthy  woman  urinates  from  four  to  six  times  in  every 
twenty-four  hours,  and  passes  in  all  from  thirty-five  to  sixty 
ounces  of  urine,  the  average  being  about  forty-five  ounces. 
The  amount  passed  varies  much  with  the  season  of  the  year, 
more  being  passed  in  winter  than  in  summer ;  it  varies  also 
with  the  amount  of  fiuid  ingesta,  rest,  and  exercise.  Neither 
limpid  nor  concentrated  urine  is  well  borne  by  the  bladder. 

The  pressure  of  the  urine  in  the  bladder  being  of  impor- 
tance in  both  health  and  disease,  I  deem  it  advisable  to  give 
here  the  results  of  some  experiments  by  Schaltz,  Odelbrecht, 
Hegar,  and  Dubois.  These  experiments  were  made  with  the 
manometer,  an  instrument  which  by  means  of  a  column  of 
mercury  may  be  adapted  to  register  the  exact  pressure  in  the 
bladder. 

They  found  the  pressure  to  be  from  twelve  to  sixteen 
inches  while  standing  ;  in  the  recumbent  posture  it  was  only 
from  four  to  six  inches.  The  pressure  in  the  recumbent  posi- 
tion Dubois  believed  to  be  due  not  to  visceral  pressure  from 
above,  but  to  the  natural  tonicity  of  the  distended  organ ; 
for  in  the  cadaver,  after  removing  the  other  viscera,  the 
pressure  in  the  bladder  indicated  four  inches,  plainly  due 
to  the  elasticity  of  the  organ  itself.  The  same  has  been  ob- 
served in  cystocele,  in  which  the  visceral  pressure  is  absent. 

The  pressure  is  about  the  same  in  both  sexes  and  at  all 
ages.  It  was  found  to  rise  from  one  half  to  one  inch  with 
each  inspiration,  and  to  fall  about  the  same  with  each  expi- 
ration. In  laughing,  coughing,  etc.,  it  rose  as  high  as  from 
twenty  to  sixty  inches.  In  diseases  of  the  spinal  cord,  such 
as  myelitis,  and  after  injuries  to  the  vertebrae,  Dubois  found 
a  marked  decrease  in  bladder  pressure. 

These  curious  observations  on  the  varying  degrees  of 
pressure  arising  from  change  of  posture  are  not  without  value. 
They  help  one  to  understand  why,  in  some  diseases  of  the 
bladder,  patients  should  maintain  the  recumbent  position. 


382  MEDICAL  GYNECOLOGY. 

There  are  many  conflicting  opinions  regarding  the  power 
of  absorption  possessed  by  the  bladder.  I  have  examined 
carefully  all  the  evidence  on  this  subject,  and  have  come  to 
the  conclusion  that  the  bladder  is  not  capable  of  absorbing 
anything,  or  but  very  little,  unless  its  epithelial  surface  is 
displaced  or  destroyed.  When  abrasion  occurs,  absorption  is 
rapid  and  its  effects  marked.  The  fact  that  the  mucous  mem- 
brane of  the  bladder  is  able  to  absorb  liquids  after  erosion  of 
its  epithelium  throws  much  light  on  the  cause  of  some  of  those 
peculiar  constitutional  symptoms  accompanying  chronic  cys- 
titis, and  known  by  some  authors  as  ammonisemia. 

The  laws  regulating  the  function  of  the  bladder  may  be 
violated  in  several  w^ays.  In  a  partly  voluntary  way  the 
evacuation  of  the  bladder  may  be  neglected  and  overdisten- 
tion  permitted  with  its  evil  results.  This  retention  is  more 
often  the  result  of  accident  or  preceding  diseases.  Too  fre- 
quent urination  and  incontinence,  partial  or  complete,  lead 
up  to  contraction  of  the  bladder  and  other  additional  well-de- 
fined states. 

If  from  any  cause  the  bladder  is  not  emptied  at  the  proper 
time,  the  organ  is  injured  by  overdistention,  and  serious  re- 
sults may  follow  if  the  retention  continues  ;  although  the 
bladder  is  too  full  to  receive  any  more  urine,  the  kidneys 
continue  to  secrete  until  not  only  the  bladder,  but  also  the 
ureters,  renal  pelves,  and  kidney  tubes  become  distended. 
When  the  pressure  on  the  urinary  side  of  the  Malpighian 
tuft  equals  that  of  the  blood-stream  in  the  glomerulus,  secre- 
tion of  urine  at  once  ceases,  and  there  is  a  mechanical  sup- 
pression. After  death  from  such  cause  the  bladder,  ureters, 
and  renal  pelves  are  found  to  be  greatly  distended,  and  the 
kidney  pale,  of  a  bluish,  pearly  color  in  the  cortex,  and 
oozing  urine  from  the  cut  surface. 

Hygiene  of  the  Urinary  Organs. — Women  are  noted  for  neg- 
lecting the  urinary  organs.  It  has  been  clearly  brought  out, 
in  describing  the  function  of  the  bladder,  that  regularity  in 
evacuating  it  is  a  necessity.  This  physiological  law  is  some- 
times unheeded  by  women.     They  often  resist  the  desire  to 


DISEASES   OF   THE   URINARY  ORGANS.  383 

urinate,  and  thereby  give  rise  to  trouble.  Many  of  the  func- 
tional disturbances  and  organic  diseases  can  be  traced  to  that 
bad  habit  of  overdis tending  the  bladder.  The  kidneys  are 
also  injured  in  the  same  way.  At  any  rate,  I  have  held  that 
opinion,  and  it  appears  reasonable  when  the  effect  of  over- 
distending  the  bladder  is  considered. 

Women  are  often  placed  in  a  position  while  traveling  or 
in  company  where  it  is  very  inconvenient  to  attend  to  their 
natural,  requirements,  and  rather  than  be  considered  rude  or 
immodest  they  suffer.  The  result  is  to  render  the  bladder  at 
first  irritable  and  hypersemic  and  then  to  cause  catarrh.  Pro- 
lapsus of  the  bladder  is  favored  by  this  overdistention.  Sud- 
den changes  from  cold  to  heat,  or  vice  versa,  are  injurious, 
not  from  "catching  cold  which  settles  in  the  bladder,"  as  is 
often  stated,  but  by  suddenly  changing  the  character  of  the 
urine,  so  that  it  becomes  irritating.  Cold  may  aid  in  causing 
irritation  by  producing  congestion,  but  sudden  changes  in  the 
quantity  and  quality  of  the  urine  are  the  chief  troubles. 

The  influence  of  the  nervous  and  nutritive  systems  upon 
the  urinary  organs  is,  of  course,  very  intimate  and  potential, 
hence  any  disturbance  of  the  one  must  act  unfavorably  upon 
the  other.  Alcohol  and  narcotics  used  in  excess  are  very  in- 
jurious, opium  being  as  objectionable  as  anything.  Food  of 
certain  kinds— i.  e.,  animal  food — should  be  used  sparingly. 
The  skin  should  be  especially  cared  for,  because  the  kidneys 
and  skin  co-operate  to  a  great  extent.  Cleanliness  of  the 
external  genital  organs  is  necessary  at  all  periods,  especially 
in  early  life  and  in  old  age.  During  the  period  of  active 
f  nnctional  life  most  women  take  ordinary  care,  but  in  child- 
hood and  old  age  there  is  frequently  great  neglect.  Vulvitis 
often  comes  from  want  of  care  in  this  respect,  and  the  inflam- 
mation of  the  vulva  extends  to  the  urethra  and  in  rare  cases 
to  the  bladder.  This  is  true  in  simple  vulvitis,  though  not 
in  so  certain  a  degree  as  in  specific  vulvitis.  In  short,  good 
general  hygienic  conditions  are  as  necessary  to  the  welfare  of 
the  urinary  organs  as  to  the  general  health. 


CHAPTER  XXXII. 

DISEASES   OF   THE   BLADDER  AND   URETHEA. 
FUNCTIONAL    DISEASES    OF    THE    BLADDER. 

CoisrsiDERABLE  time  and  space  will  be  occupied  with  the 
functional  diseases  of  the  urinary  organs,  for  the  reason  that 
women  suffer  very  much  from  these  disorders — far  more  so 
than  men.  From  my  observatix)n  I  have  concluded  that 
women  are  as  prone  to  functional  affections  of  the  bladder  as 
to  disease  of  the  uterus. 

The  rule  among  pathologists  appears  to  be,  to  class  under 
the  head  of  functional  diseases  all  those  in  which  no  lesion  of 
structure  is  discoverable  in  the  organs  concerned.  Although 
still  following  this  rule,  the  progress  in  diagnosis  during  the 
past  few  years  has  weeded  out  many  of  the  so-called  func- 
tional effections ;  and  as  this  knowledge  advances,  and  new 
and  efficient  means  for  observation  and  study  arise,  many 
more  will  be  rooted  out,  thus  doing  away  with  much  of  the 
vagueness  and  uncertainty  in  which  this  class  of  affections 
are  shrouded.  But  even  with  the  improved  facilities  for  di- 
agnosis at  our  command,  there  are  still  many  diseases  in  this 
list.  Owing  to  the  obscurity  at  present  surrounding  the  sub- 
ject of  reflex  or  sympathetic  disorders — i.  e.,  the  abnormal 
condition  of  an  organ  or  organs,  near  or  distant,  affecting  the 
function  or  nutrition  of  other  organs — we  are  obliged  to  put 
these  affections  in  this  class  also.  The  functional  and  organic 
diseases  of  the  urinary  organs  are  intimately  related,  and  the 
derangement  of  function  depends  upon  such  diverse  causes 
that  a  classification  and  arrangement,  though  difficult,  are 
required,  and  hence  an  effort  will  be  made  to  furnish  one. 
I  have  adopted  the  following  arrangement : 

384 


DISEASES   OF  THE  BLADDER  AND   URETHRA.  385 

Functional  derangements  caused  by — First.  Certain  pecul- 
iarities and  imperfections  of  local  innervation  of  the  bladder 
and  urethra ;  Second.  Caused  by  diseases  and  derangements 
of  the  general  nervous  system  ;  Third.  Due  to  diseases  of  the 
nutritive  system,  including  certain  toxic  conditions ;  and, 
Fourth.  Caused  by  diseases  of  the  other  pelvic  organs. 

Examples  of  the  first  class  are  seen  in  irritable  bladder, 
manifested  in  some  cases  by  frequent  urination  and  in  others 
by  incontinence. 

Hysteria  and  diseases  of  the  brain  and  spinal  cord  give 
typical  examples  of  the  second  class. 

The  third  class  is  illustrated  in  malarial  and  eruptive 
fevers,  excrementitious  plethora,  and  other  constitutional  dis- 
eases. 

Cases  of  the  fourth  class  are  seen  in  ovaritis,  metritis, 
pelvic  peritonitis,  and  displacements  of  the  uterus. 

These  are  the  functional  diseases  vt^hich  generally  come 
under  the  care  of  the  physician.  There  are  also  certain  acute 
diseases,  such  as  acute  cystitis  and  urethritis,  which  are 
managed  best  by  medical  treatment. 

In  this  arrangement  of  the  subject,  although  a  number  of 
structural  diseases  are  considered,  they  all  stand  in  a  causa- 
tive relation  to  the  disturbed  action  of  the  bladder,  the  latter 
being  free  from  any  organic  lesion,  and  only  disturbed  in  the 
discharge  of  its  duty  by  influences  outside  of  itself. 

Before  discussing  these  functional  disorders  in  detail  it 
will  be  necessary  to  fix  clearly  in  mind  their  various  manifes- 
tations. These  are :  frequent  urination,  or  polyuria  ;  difficult 
urination  and  retention,  or  ischuria ;  painful  urination,  or 
dysuria  ;  pain  after  urination,  or  vesical  tenesmus  ;  and  in- 
continence of  urine,  or  enuresis.  These  deranged  actions 
may  also  occur  in  organic  diseases  of  the  bladder  as  well  as 
in  the  four  classes  of  functional  derangements  at  present 
under  consideration. 

The  examination  and  diagnosis  of  cases  of  functional  dis- 
eases of  the  urinary  organs  call  for  brief  mention  here.  The 
method  which  I  have  followed  most  successfully  is,  first  to 


386  MEDICAL  GYNECOLOGY. 

obtain  the  symptoms  and  determine  from  these  the  class  of 
functional  derangements  to  which  the  case  in  question  be- 
longs. The  next  step  is  to  determine  whether  the  bladder  or 
urethra  is  involved,  or  if  the  trouble  is  due  to  conditions  of 
the  general  organization.  This  question  is  settled  by  exclu- 
sion, if  there  is  no  disease  of  the  general  organization  to  ac- 
count for  the  affection  of  the  urinary  organs.  The  urine  is 
examined,  and  that  either  excludes  or  detects  disease  of  the 
urinary  organs.  By  pursuing  this  method,  a  diagnosis  can 
be  easily  and  correctly  made  in  the  majority  of  cases, 

Urethro-vesical  Neuroses. — By  this  term  I  refer  to  purely 
nervous  affections  of  this  organ.  They  are  rather  rare,  it  is 
true,  but  there  is  no  doubt  that  they  do  exist,  for  there  are 
certain  cases  that  seem  to  depend  on  no  other  known  patho- 
logical lesion.  The  books  state  that  vesical  neuralgia  is  of 
this  class.  It  is  known  by  a  variety  of  names,  each  taking  as 
its  keynote  some  peculiar  manifestation  or  symptom,  as  irri- 
table bladder,  cystospasm,  cystoplegia,  and  neuralgia  vesicae. 

The  term  irritability  so  commonly  used  in  speaking  of  the 
healthy  organ  must  not  be  confounded  with  the  condition 
known  as  irritable  bladder.  The  former  refers  to  a  certain 
peculiarity  that  the  viscus  possesses,  by  means  of  which  it  is 
able  to  respond  to  certain  stimuli,  while  the  latter  refers  to 
an  abnormal  condition  of  sensation — viz.,  supersensibility,  or 
hypersesthesia. 

In  the  great  majority  of  cases  of  these  attacks  of  pain  the 
cause  can  be  traced  to  some  of  the  conditions  which  give  rise 
to  neuralgia  in  general,  such  as  malaria,  anaemia,  and  nerve 
exhaustion.  It  appears  to  be  a  pure  neuralgia — i.  e.,  a  tem- 
porary disease  of  the  nerve  or  nerves  involved.  The  attacks 
come  on  periodically,  but  irregularly.  There  is  no  evidence 
of  cystitis  or  urethritis,  neither  is  there  any  change  in  the 
composition  of  the  urine  that  would  account  for  the  pain. 
The  best  idea  of  this  affection  can  be  conveyed  by  the  history 
of  the  most  typical  case  that  I  have  found  among  a  number. 

Neuralgia  of  the  Urethra  and  Neck  of  the  Bladder. — A  woman 
twenty- six  years  of  age,  three  years  married,  had  never  been 


DISEASES   OP   THE   BLADDER  AND   URETHRA.  387 

pregnant.  She  was  well  developed,  and,  although  of  a 
marked  nervous  temperament,  had  always  enjoyed  good 
health.  From  puberty  onward  she  had  suffered  pain  at  her 
menstrual  periods,  but  not  of  a  severe  character.  When  she 
was  twenty-four  years  old  she  was  chilled  while  riding  a  long 
distance  on  a  cold  day,  which  was  followed  by  frequent  and 
painful  urination.  This  was  relieved  by  rest  and  diuretics, 
but  from  that  time  she  was  subject  to  violent  attacks  of  spas- 
modic pain  in  the  urethra  and  bladder.  The  pain  was  of  a 
sharp,  lancinating  character,  and  though  generally  coming  on 
before  and  after  her  menstrual  period,  was  brought  on  at  any 
time  by  nervous  excitement  or  great  fatigue.  During  the 
pain  there  was  some  difficulty  in  urinating,  but  the  suffering 
was  neither  relieved  nor  increased  by  the  act.  The  duration 
of  the  pain  varied,  but  usually  did  not  last  more  than  twenty- 
four  hours.  Large  doses  of  opium  would  relieve  her,  but,  as 
it  caused  very  distressing  after-effects,  she  avoided  taking  it 
except  when  the  attacks  were  exceptionally  severe  and  pro- 
longed. She  was  treated  for  a  uterine  flexion,  and  obtained 
complete  relief  from  the  painful  menstruation  and  tenderness 
of  the  pelvic  organs  generally,  but  there  was  no  relief  from 
the  periodic  attacks  of  pain  in  the  urethra  and  bladder.  She 
acknowledged  that  it  was  not  quite  so  severe  as  formerly 
at  her  menstrual  periods,  but  was  "bad  enough  in  all  con- 
science," as  she  expressed  it. 

Careful  and  repeated  examinations  of  the  urine  were  made 
when  she  suffered  and  when  she  was  free  from  it,  but  no 
trace  of  any  renal,  vesical,  or  urethral  disease  was  found. 
The  urethra  and  neck  of  the  bladder  were  examined  with  the 
endoscope  several  times,  but  were  found  to  be  normal.  Sus- 
pecting that  the  neuralgic  pain — for  such  it  apparently  was — 
might  be  due  to  malaria,  she  was  given  fifteen  grains  of  qui- 
nine within  a  period  of  four  hours,  followed  by  Fowler's  solu- 
tion of  arsenic  in  doses  of  three  minims  after  each  meal.  The 
arsenic  treatment  was  continued  for  several  weeks,  and  gave 
her  some  relief,  the  attacks  being  less  violent,  but  still  she 
suffered  greatly. 


388  MEDICAL  GYNECOLOGY. 

Moderate  dilatation  of  tlie  urethra  was  then  practiced,  but 
this  only  aggravated  the  trouble.  Several  different  remedial 
agents — including  opium,  hot  water,  aconite,  infusion  of  hops, 
and  belladonna — were  injected  into  the  bladder,  but  none  of 
them  gave  any  relief.  The  citrate  of  iron  and  quinine  in  five- 
grain  doses  was  then  prescribed  to  be  taken  before  meals,  and 
Parrish's  compound  sirup  of  the  phosphates  in  drachm  doses 
to  be  taken  after  meals.  When  the  pain  came  on  she  was 
directed  to  take  every  three  hours  a  drachm  of  camphor- 
water  containing  eight  grains  of  muriate  of  ammonia,  and  to 
use  a  vaginal  douche  of  hot  water.  This  treatment  usually 
resulted  in  mitigating  the  pain,  but  did  not  completely  remove 
it.  Thirty  minims  of  the  compound  spirits  of  ether  and  five 
minims  of  the  tincture  of  cannabis  Indica  every  four  hours 
were  substituted  for  the  camphor-water  and  muriate  of  am- 
monia, and  with  good  effect.  Under  this  treatment  her  attacks 
were  far  less  frequent,  and  the  relief  from  pain  was  prompt. 
She  was  so  much  pleased  with  her  imx)rovement  that  she  took 
a  trip  through  the  West  and  returned  quite  well,  and  has  re- 
mained so  for  the  past  eight  years.  More  recently  I  have  had 
a  case  which  resembled  this  one  in  many  respects,  particularly 
as  regards  the  character  of  the  pain  and  its  causation,  in 
which  a  four-per-cent  solution  of  muriate  of  cocaine  instilled 
into  the  urethra  and  bladder  gave  relief. 

Derangements  due  to  Abuse  of  the  Sexual  Functions. — Frequency 
of  urination  is  the  chief  symptom  in  this  class  and  is  caused 
by  the  habit  of  masturbation.  The  constant  congestion  and 
irritability  of  the  pelvic  organs,  caused  by  the  unnatural  and 
excessive  exercise  of  the  sexual  function,  give  rise  to  frequent 
urination.  Such  patients  complain  of  general  weakness,  which 
is  not  accounted  for  by  any  organic  disease  of  the  system. 
Nor  is  there  disease  of  the  bladder  ;  it  is  simply  enfeebled 
and  irritable  like  the  rest  of  the  pelvic  organs.  To  make  a 
correct  and  positive  diagnosis  in  such  cases  is  by  no  means 
easy,  because  it  necessitates  detecting  the  habit  of  noasturba- 
tion,  and  this  is  usually  one  of  the  most  difficult  tasks  for  the 
diagnostician.     It  is  not  always  prudent  to  question  patients 


DISEASES  OF   THE  BLADDER  AND   URETHRA.  389 

directly  regarding  the  habit ;  and  even  when  that  is  done 
they  frequently  fail  to  comprehend  the  question,  or  they 
answer  falsely  in  the  negative.  The  physician  is  thus  gen- 
erally left  to  guess  at  the  truth  of  the  matter. 

The  symptoms  developed  by  masturbation  are  depression 
of  the  nervous  system,  manifested  by  lassitude,  sadness,  or 
emotional  expressions  of  joy  and  sorrow,  those  affected  with 
this  habit  being  easily  moved  to  smiles  or  tears.  The  eyes 
are  dreamy  and  heavy,  and  the  pupils  dilated.  Such  subjects 
are  excitable,  irritable,  and  easily  exhausted,  and  often  have 
headaches.  JSTutrition  is  apparently  good  in  some  cases,  as 
is  shown  by  the  fair  suiDjDly  of  flesh  ;  still,  they  often  suf- 
fer from  acute  indigestion,  although  at  times  the  appetite  is 
remarkably  good.  The  bowels  are  usually  constipated,  and 
the  muscles  are  soft  and  flabby.  The  exhalations  from  the 
skin  are  sometimes  changed,  so  that  a  peculiar  odor  is  notice- 
able about  such  persons.  This  odor  can  not  be  described, 
but,  when  once  recognized,  is  easily  remembered. 

In  this  variety  of  functional  derangement  of  the  bladder, 
as  well  as  in  all  the  other  varieties  of  neurotic  affections,  the 
symptoms  vary  in  severity  to  a  great  extent  in  the  same  indi- 
vidual. The  trouble  is  by  no  means  regular  and  constant  in 
its  manifestations,  as  in  organic  diseases.  Whatever  disturbs 
the  nervous  system  will  increase  the  disorder.  The  rule  is 
that  frequent  urination  is  the  prominent  symptom,  but  occa- 
sionally pain  accompanying  the  act  is  complained  of.  It  is 
then  simply  a  slight  scalding  pain,  experienced  when  the 
urine  is  passing  over  the  irritable  or  chafed  mucous  mem- 
brane about  the  meatus  urinarius. 

I  remember  a  girl  nineteen  years  of  age,  who  had  a  well- 
developed  general  organization  and  enjoyed  good  health  up 
to  puberty  at  fourteen,  who  sought  advice  regarding  "impa- 
tience" of  her  bladder.  She  was  obliged  to  return  home  from 
boarding  school  because  she  had  to  urinate  so  often  that  she 
could  not  attend  to  her  studies  and  recitations.  Her  general 
nutrition  was  good,  and  she  menstruated  regularly,  freely, 
and  without  acute  pain.     Her  nervous  system  was  depressed ; 


390  MEDICAL  GYNECOLOGY. 

sometimes  she  was  languid,  low-spirited  and  fretful,  and  at 
other  times  was  bright  and  disposed  to  be  cheerful.  Her  man- 
ner was  rather  timid  and  excited.  Her  hands  were  clammy, 
and  her  eyes  dull  and  had  dark  streaks  under  them.  Her 
chief  symptom  was  the  frequent  urination  which  persisted, 
but  was  much  worse  at  times  than  at  others.  Occasionally 
she  would  pass  the  night  without  getting  up  more  than  once 
or  twice,  but  during  the  day  she  was  often  obliged  to  urinate 
every  half  hour.  There  was  very  little  pain  except  occasion- 
ally a  little  smarting  at  the  meatus.  She  complained  of  heat 
and  burning  about  the  vulva  and  occasional  aching  in  the 
region  of  the  ovaries.  She  was  easily  fatigued  and  had  back- 
ache, especially  on  standing  and  walking ;  leucorrhoea  troubled 
her  only  at  times. 

I  suspected  at  first  that  she  had  either  cystic  and  urethral 
congestion,  or  else  hysteria  giving  rise  to  excessive  renal  secre- 
tion of  limpid  urine  ;  but  an  examination  of  the  quantity  and 
composition  of  the  urine  proved  the  contrary.  She  was  put 
in  charge  of  a  very  competent  nurse,  who  was  directed  to  find 
out  the  habits  of  the  patient. 

The  report  of  the  attendant  was  that  she  had  begun  to  in- 
dulge in  masturbation  soon  after  puberty,  and  that  the  habit 
had  gradually  grown  upon  her.  Her  nurse  surprised  her  by 
telling  her  the  cause  of  her  suffering,  and  readily  gained  her 
consent  to  make  all  due  efforts  to  recover  her  self-control. 
By  care,  occuj^ation,  exercise  out  of  doors,  and  the  moral  con- 
trol of  her  nurse,  she  began  to  improve.  Bromide  of  sodium 
was  given  when  she  was  very  restless  and  irritable,  but  no 
other  medication  except  free  bathing. 

In  about  two  months  the  frequent  urination  had  disap- 
peared, although  she  would  occasionally  have  a  day  or  a 
night  when  she  suffered  a  little  in  that  way.  She  now  has 
two  children  and  enjoys  life  very  well,  being  free  from  her 
former  symptoms  and  no  doubt  cured  of  her  former  habit. 

Frequent  and  Difficult  "Urination  from  Sexual  Continence. — That 
this  affection  is  not  rare  I  saw  exemplified  in  a  strong  and 
active  lady  in  good  circumstances,  who  married  at  twenty-one 


DISEASES  OF  THE  BLADDER  AND   URETHRA.  39I 

years  of  age,  who  had  her  first  baby  before  she  was  twenty- 
two,  and  who  nursed  the  child  for  eighteen  months.  Her 
menses  came  on  when  the  child  was  one  year  old.  About 
three  years  after  her  marriage  her  husband,  a  strong,  vigor- 
ous man,  died  of  pneumonia.  Several  months  after  the  loss 
of  her  husband  she  began  to  suffer  at  times  from  frequent 
urination,  and  also  had  some  difiiculty  in  voiding  her  urine, 
voluntary  efforts  being  necessary  to  do  so.  These  attacks 
would  pass  off,  and  she  would  be  comfortable  for  days,  when 
the  same  irritation  of  the  bladder  would  return.  She  was 
always  made  worse  by  excitement,  often  being  kept  awake 
nearly  all  night  after  spending  the  evening  in  company. 

Her  Symptoms  became  so  troublesome  that  she  sought 
advice  of  a  physician,  who  treated  her  for  cystitis  by  giving 
medicines  of  various  kinds.  When  she  first  came  under  my 
observation  I  found  her  in  perfect  health  in  every  way.  The 
urine  was  normal,  and  caused  no  pain  in  passing.  I  was 
easily  able  to  exclude  all  diseases  except  deranged  inner- 
vation from  a  possible  malarial  influence.  The  periodical 
character  of  the  attacks  favored  this  view  of  the  case,  but  the 
use  of  the  antimalarial  remedies  gave  no  relief.  I  then  or- 
dered her  to  take  more  active  exercise  and  a  limited  quantity 
of  plain  food,  to  bathe  frequently,  and  to  avoid  excitement  as 
far  as  possible.  Bromide  of  sodium  was  also  given  when  her 
suffering  was  most  severe.  She  improved  on  this  treatment 
for  a  time;  in  fact,  she  became  so  much  better  that  I  lost 
sight  of  her  for  nearly  a  year,  when  she  returned,,  to  say 
that  her  former  symptoms  had  reappeared  and  were  about 
as  troublesome  as  before.  The  same  treatment  was  em- 
ployed, but  did  not  help  her  very  much.  She  was  then 
rather  nervous  and  restless,  and  disposed  to  be  emotional. 
Three  months  afterward  she  was  married,  and  left  the  city 
on  an  extended  wedding  tour.  Upon  her  return  she  reported 
herself  as  perfectly  well. 

Incontinence  of  Urine. — Enuresis  nocturna  is  usually  an  af- 
fection of  childhood,  but  has  been  known  to  persist  up  to  the 
age  of  thirty  years.     In  some  children  it  is  hereditary.     One 


392  MEDICAL  GYNECOLOGY. 

mother  is  reported  as  having  suffered  in  early  life,  and  all  the 
children  born  to  her  were  affected  in  the  same  way.  Patients 
to  whom  the  affection  is  transmitted  are  the  most  difficult 
to  manage,  and  they  often  continue  to  suffer  until  puberty. 
The  subjects  of  this  affection  are  usually  of  the  weak,  nerv- 
ous type,  although  healthy  children  have  been  known  to 
have  it,  but  only  at  intervals. 

Cases  of  incontinence  may  be  divided  into  two  distinct 
varieties :  First,  the  anaesthetic  variety,  an  excellent  example 
of  which  class  is  seen  in  infants,  to  whom  it  is  normal  up  to 
a  certain  age.  The  incontinence  in  severe  fevers  illustrates 
the  abnormal  phase  of  the  same  thing  in  adults.  Secondly, 
the  hyper£esthetic  variety,  which  is  really  nothing  more  than 
irritable  bladder.  Each  variety  may  exist  alone,  or  both  may 
be  combined  in  one  case. 

In  the  first  variety  the  retaining  power  is  defective,  the  re- 
sisting power  of  the  sphincter  being  insufficient.  When  the 
child  is  put  to  bed  it  sleeps  soundly  through  the  night,  and 
the  nerve  susceptibility  to  urine  pressure  on  the  neck  of  the 
bladder,  being  lowered  beyond  the  normal  degree,  fails  to 
wake  the  little  subject  and  impress  it  with  the  necessity  of 
calling  the  s]3hincter  muscle  into  action  sufficiently  to  resist 
the  expulsive  power  of  the  bladder  walls.  In  short,  in  sound 
sleep  the  balance  between  the  resisting  power  of  the  sphincter 
and  the  contractility  of  the  walls  of  the  bladder  is  disturbed, 
and  the  urine  flows  away  without  the  child's  even  dreaming 
of  its  unfortunate  behavior. 

In  other  forms  of  this  affection  the  brain  takes  cognizance 
of  the  desire  to  urinate,  but  too  late  to  control  the  act.  This 
is  seen  in  children  who  awake  crying  when  urination  is  but 
just  begun  or  half  finished.  In  this  case  the  fault  probably 
lies  in  the  vesical  nerves,  perhaps  wholly  so. 

In  the  second  variety  there  is  an  irritable  condition  of 
the  bladder  (vesical  hypersesthesia),  which  renders  the  expel- 
ling power  greater  than  that  of  resistance  or  retention,  and, 
while  the  will  and  cerebration  generally  are  lost  in  sleep,  the 
contents  of  the  bladder  are  unconsciously  passed  before  the 


DISEASES  OF   THE   BLADDER  AND   URETHRA.  393 

subject  awakes  to  resist  the  act.  Closely  allied  to  this  is  the 
peculiar  affection  known  as  vesical  chorea,  in  which  the  child 
while  awake — it  may  be  in  school  or  at  play— suddenly  ex- 
periences the  sensation  that  it  is  about  to  make  water ;  but, 
before  it  is  possible  to  resist,  the  urine  is  forcibly  spurted  out. 
There  are  usually  choreic  movements  of  other  muscles  or 
grou^DS  of  muscles.  This  affection  is  most  annoying,  and  may 
be  accompanied  by  nocturnal  enu^resis.  It  is  apparently  more 
common  iij  the  male  than  in  the  female  child. 

An  irritable  condition  of  the  bladder  may  coexist  with  an 
anaesthetic  condition  of  the  sphincter  vesicae — i.  e.,  the  two 
causes  of  incontinence  may  be  combined.  Irritable  bladder 
may  be  due  to  some  neurosis,  or  to  abnormal  urine,  or  reflex 
irritation  from  anal  fissure,  ascarides  in  the  rectum,  fistula  in 
ano,  haemorrhoids,  or  vulvitis. 

Enuresis  nocturna  is  not  only  a  filthy  habit,  and  a  source 
of  great  annoyance  to  parents,  but,  moreover,  by  keeping  the 
genitals  wet  and  irritable,  strongly  predisposes  to  bad  habits. 
Then,  too,  other  serious  results  may  happen.  The  constant 
wettings  are  dangerous,  in  that  they  may  produce  many  seri- 
ous complaints  from  causing  the  child  to  "take  cold." 

Causation. — This  subject  has  not  been  fully  worked  up, 
perhaps  because  of  the  difficulties  encountered  in  the  investi- 
gation. It  is  evident  that  there  are  many,  or  at  least  several, 
predisposing  and  exciting  causes.  Some  defect  in  the  nervous 
system,  either  central  or  peripheral,  is  apparently  the  predis- 
posing cause  in  some  cases,  but  my  own  impression  is  that  it 
is  a  habit  brought  about  by  mismanagement  in  infancy  and 
childhood.  As  early  as  the  ninth  month  most  children  mani- 
fest the  desire  to  urinate  by  fretting  or  crying,  and  if  the 
attendant  will  at  once  undo  the  clothing  and  place  the  little 
one  in  a  proper  position,  erect  or  sitting,  it  will  urinate.  At 
any  rate,  by  regularly,  at  stated  times,  inviting  a  child  to 
urinate,  normal  habits  will  be  established  in  this  respect. 
Though  some  intelligent  mothers  and  nurses  do  remarkably 
well  so  far  as  this  is  concerned,  a  great  many  manage  badly, 
leaving  their  children  day  and  night  to  urinate  when  and 


394  MEDICAL  GYNECOLOGY. 

where  they  please.  I  have  investigated  quite  a  number  of 
cases  in  relation  to  causation,  and  have  found  evidence  in 
nearly  all  that  they  had  been  left  to  the  freedom  of  their 
want  of  will  in  childhood. 

The  exciting  cause,  which  is  operative  in  those  who  have 
been  all  right  up  to  a  given  time  and  then  taken  up  the  habit, 
is  irritation  of  the  bladder  from  the  eruptive  fevers,  taking 
cold,  ascarides,  anal  fissure,  and  haemorrhoids,  or  urine  that 
is  irritating  from  excess  of  uric  acid.  Concentrated  urine  may 
cause  irritation  and  frequent  urination,  and  this  frequency 
is  likely  to  continue  after  the  cause  is  removed.  Excessive 
secretion  and  hence  limpid  urine,  which  is  often  present  in 
artificially  fed  children,  gives  the  same  results  as  concentrated 
urine.  Improper  feeding  and  neglect  or  mismanagement  is 
the  chief  cause  of  incontinence,  as  I  have  observed. 

Prognosis. — In  some  cases  the  cure  is  easily  and  speedily 
effected ;  in  others  the  trouble  cures  itself  at  or  Just  after 
puberty  ;  but  in  a  few— a  very  small  percentage — no  medical 
or  other  means  seems  to  aid  the  sufferer  at  all. 

Treatment. — That  the  treatment  is  not  uniformly  satisfac- 
tory is  seen  by  the  number  of  remedies  that  have  been  tried. 
The  proper  way  is  to  find  and  remove  the  cause  producing  the 
disease,  if  it  be  discoverable,  and  it  generally  is.  The  treat- 
ment will,  of  course,  differ  in  the  two  classes,  and  be  greatly 
modified  by  diathesis  and  idiosyncrasy.  In  anaesthesia,  local 
or  general,  stimulation  is  indicated.  In  hypersesthesia,  irri- 
tability should  be  allayed. 

Winckel,  Barclay,  and  Brugleman  speak  very  highly  of 
the  use  of  the  syrupus  ferri  iodidi,  the  last-named  gentleman 
having  by  its  use  perfectly  cured  a  girl  of  incontinence  in  the 
short  space  of  fourteen  days.  This  result  was  probably  due 
more  to  the  effect  of  the  medicine  on  the  blood  and  general 
system  than  to  any  specific  action  on  the  bladder.  The 
sirup  of  the  iodide  may  be  given  in  from  ten  to  thirty  minim 
doses  three  or  four  times  daily,  according  to  the  age  of  the 
patient. 

Although  belladonna  has  been  lauded  by  many  as  a  spe- 


DISEASES  OF   THE  BLADDER  AND  URETHRA.  395 

cific  in  this  disorder,  its  success  is  by  no  means  universal.  The 
drug  is  usually  given  by  the  mouth,  in  from  five  to  twenty  drop 
doses  of  the  officinal  tincture.  It  would  be  better  to  begin 
with  small  doses  in  the  case  of  young  children,  and  gradually 
increase  them ;  for,  although  no  serious  results  may  come 
from  its  use  in  the  routine  dose — ten  drops — the  parents  may 
be  greatly  alarmed  by  the  peculiar  redness  of  the  skin,  dry 
throat,  and  dilatation  of  the  pupils  produced  in  certain  cases. 
It  is  maintained  by  some  medical  men  that  the  good  effects 
are  not  obtained  unless  the  administration  be  pushed  to  the 
appearance  of  the  scarlet  rash.  There  is,  I  think,  no  proof 
of  the  correctness  of  this  statement. 

A  combination  of  belladonna  and  chloral  hydrate  has  been 
used  and  well  spoken  of.  Winckel,  however,  though  using 
them  in  certain  cases  for  a  long  time,  and  daily  increasing  the 
amount  of  chloral,  has  had  but  poor  results,  and  even  in  in- 
stances where  the  patients  improved,  the  benefit  was  seldom 
permanent.  These  drugs  may  be  given  singly  or  together,  in 
suppository  or  by  the  mouth.  If  given  together,  they  should 
not  be  combined  until  the  time  when  they  are  administered, 
lest  the  chloral  decompose  and  lose  its  power. 

Narcotics  with  tinctura  ferri  chloridi  have  been  recom- 
mended by  Campbell  Black.  Winckel  speaks  well  of  five  to 
ten  drop  doses  of  tinctura  thebaica  in  the  case  of  a  child  from 
ten  to  fourteen  years  of  age,  just  before  retiring.  According 
to  Sauvage,  cold  baths  and  cold  douches  to  the  spine  at  night 
are  of  great  service. 

Dr.  Kelp  (Le  Mouvement  Medicale)  reports  that  he  has  on 
several  occasions  drawn  attention  to  the  value  of  subcutane- 
ous injections  of  the  nitrate  of  strychnine  in  the  treatment  of 
obstinate  cases  of  nocturnal  incontinence.  He  gives  the  injec- 
tions in  the  neighborhood  of  the  sacrum.  A  single  injection 
of  a  very  small  quantity  of  the  drug  suffices  to  arrest  the 
affection  for  a  certain  time,  and  when  it  reappears  the  hypo- 
dermic application  can  be  lepeated.  His  latest  paper  cites 
the  case  of  a  young  woman,  eighteen  years  of  age,  who  had 
suffered  from  enuresis  every  night  for  several  months ;   it 

26 


306  MEDICAL  GYNECOLOGY, 

came  on  after  an  attack  of  scarlatina,  and  persisted  in  spite 
of  all  precautions.  The  first  injection  secured  a  respite  of 
several  nights,  and  the  second  produced  a  permanent  cure. 
The  patient  was  a  strong,  healthy  girl,  and  had  never  suf- 
fered from  enuresis  previous  to  the  attack  of  scarlatina. 

Such  a  plan  of  treatment  I  regard  as  useful  only  when 
there  is  deranged  innervation,  characterized  by  weakness.  It 
would  be  difficult  to  get  a  child  to  submit  to  these  injections 
if  long  continued,  and  I  should  in  any  case,  whether  child  or 
adult,  expect  the  incontinence  to  return  as  soon  as  the  strych- 
nine was  discontinued. 

In  cases  where  the  vesical  irritability  is  due  to  abnormity 
of  the  urine,  such  as  lithiasis,  oxaluria,  and  acidity,  these 
conditions  should  be  corrected  in  the  manner  I  have  pointed 
out  elsewhere.  If  due  to  ascarides,  anal  fissure,  and  that 
class  of  rectal  trouble,  the  difficulty  will  usually  disappear 
when  the  cause  is  removed.  In  irritability  the  usual  sooth- 
ing and  demulcent  drinks  should  be  used.  Oil  of  sandal- 
wood has  acted  remarkably  well  in  some  of  these  cases ;  in 
others,  bromide  of  sodium  and  tincture  of  nux  vomica  have 
been  effectual. 

In  the  anaesthetic  variety,  where  the  anaesthesia  is  local  or 
general  and  more  or  less  marked,  stimulants  should  be  em- 
ployed. Narcotics  are  as  hurtful  here  as  they  are  useful  in 
the  hypergesthetic  class.  Strychnine  by  the  mouth,  in  sup- 
pository or  hypodermically,  often  produces  good  results,  as 
also  quinine,  whether  the  presence  of  malaria  is  suspected  or 
not.  When  the  bladder  is  small  and  refuses  to  be  distended  in 
the  natural  way,  great  benefit  can  be  obtained  by  teaching  the 
child  to  retain  her  urine  as  long  as  possible  during  the  day. 
This  is  most  important  in  all  instances,  especially  in  the 
contracted  bladder  cases,  but  to  be  effective  it  must  be  very 
systematically  carried  out.  The  patient  should  be  carefully 
watched  and  kept  interested  to  divert  attention  from  the  uri- 
nary organs  ;  then,  when  the  desire  comes,  convenience  for 
urinating  should  be  at  hand.  The  time  should  be  noted,  and 
the  patient  directed  to  refrain  longer  on  each  subsequent  oc- 


DISEASES  OP  THE  BLADDER  AND  URETHRA.  397 

casion.  Better  still,  the  attendant  should  direct  this,  so  that 
the  patient  may  not  have  to  think  about  it. 

This  one  factor  in  the  treatment  (when  the  patient  will 
co-operate,  or  where  an  attendant  can  be  procured  who  will 
carry  out  the  directions)  is  the  most  valuable  of  all.  In  cases 
of  abnormally  small  bladder,  washing  out  the  bladder  and 
distending  it  a  little  more  each  time  is  well  spoken  of.  In 
one  such  instance,  where  there  was  irritability,  Winckel  pro- 
duced a  cure  by  first  injecting  a  solution  of  nitrate  of  silver, 
and  following  it  with  suljohate  of  morphine.  This  treatment, 
however,  applies  more  to  the  irritable  than  to  the  anaesthetic 
type.  The  little  patients  are  very  hard  to  0]3erate  upon,  and, 
unless  great  care  is  exercised,  much  mischief  may  be  caused 
by  local  treatment.  This,  however,  belongs  to  the  domain  of 
surgery. 

Winckel  claims  good  results  from  the  use  of  the  electric 
current,  applied  in  the  manner  spoken  of  under  the  head  of 
paresis  vesicae. 

When  the  bed-wetting  is  due  to  pure  carelessness,  lazi- 
ness, fear,  or  dread  of  the  cold  air  in  rising,  in  idiots  and 
half-witted  children,  much  may  be  gained  by  proper  educa- 
tion. 

There  is  a  general  plan  of  prophylaxis  recommended  by 
common  sense — viz.,  the  heartiest  meal  should  be  in  the 
middle  of  the  day  ;  but  little  water  ought  be  taken  toward 
evening,  and  the  food  be  plain  and  unseasoned.  The  bowels 
should  be  kept  regular ;  no  coffee  or  tea  allowed,  and  the 
little  patients  put  to  bed  early,  after  it  is  assured  that  the 
bladder  is  first  thoroughly  emptied.  They  should  lie  upon 
a  hard  bed,  with  not  too  much  covering  ;  the  air  in  the  room 
be  maintained  fresh  and  pure,  and  the  genitals  kept  clean 
and  dry.  No  places  of  amusement  ought  be  visited  after 
dark ;  and  they  should  occasionally  be  awakened  to  urinate, 
especially  at  about  the  time  the  parents  are  going  to  bed. 
When  it  is  discovered  that  they  have  wet  the  bed,  they  must 
be  awakened,  and  talked  to  and  reasoned  with,  if  they  are 
able  to  comprehend  what  is  said  and  meant. 


398  MEDICAL  GYNECOLOGY. 

CMldren  should  not  go  to  school  too  early,  or  stay  there 
too  long.  If  the  enuresis  be  due  to  masturbation,  the  parents 
must  be  cautioned  to  watch  closely,  and  to  use  every  means 
in  their  power  to  stop  it.  A  child  ought  never  be  whipped 
for  the  offense  or  misfortune  of  wetting  the  bed  unless  the 
incontinence  be  due  to  pure  laziness,  and  I  doubt  if  it  ever  is. 

Owing  to  the  fact  that  incontinence  is  an  aft'ection  of 
childhood,  and  occurs  but  seldom  in  women,  cases  will  not 
be  given  to  illustrate  what  is  said  in  the  text  on  that  subject. 
This  omission  is  made  for  the  additional  reason  that  partial 
incontinence,  due  to  displacements  of  the  bladder  and  urethra 
and  from  other  causes,  is  discussed  fully  in  my  work  on  the 
Surgical  Diseases  of  Women. 


CHAPTER  XXXIII. 

FUNCTIOJSTAL  DISEASES  OF   THE   BLADDER,  CAUSED  BY  CERTAIN 
AFEECTIOlSrS   OF   THE   GENERAL   NERVOUS   SYSTEM. 

There  are  many  nervous  women  who  are  annoyed  by  fre- 
quent urination  wlien  excited  in  any  way.  They  are  not 
hysterical,  but  sensitive  and  sympathetic.  Fear,  joy,  sorrow, 
or  expectation  will  bring  on  an  attack,  and  the  more  they 
urinate  the  more  they  incline  to  do  so.  I  have  found  in  such 
cases  that  by  exercising  the  will-power  to  resist  the  inclina- 
tion, they  improve  without  further  treatment. 

Derangements  due  to  Hysteria. — Hysteria  holds  a  prominent 
place  among  the  causes  of  functional  derangement  of  the 
bladder,  the  vesical  affection  probably  being  only  a  fragment 
of  a  general  neurosis.  Any  one  who  has  suffered  the  morti- 
fication of  an  involuntary  evacuation  of  urine  from  fear  will 
understand  how  the  brain  and  nervous  system  can  influence 
the  bladder. 

In  the  variety  of  conditions  grouped  under  the  head  of 
hysteria  it  is  often  observed  that  frequent  urination  is  a 
prominent  symptom.  The  cause,  in  many  cases,  is  the  pe- 
culiar character  of  the  urine  secreted  in  this  disturbed  con- 
dition of  the  nervous  system.  The  urine  of  hysterical  pa- 
tients is  deficient  in  solids,  the  watery  portion  being  greatly 
in  excess.  This  unnatural  composition  renders  the  urine  irri- 
tating to  the  bladder,  so  that  it  can  not  long  be  retained.  The 
quantity  of  urine  secreted  is,  at  certain  times,  excessive, 
which,  together  with  its  irritating  quality,  renders  urination 
necessarily  very  frequent. 

But  apart  from  the  frequent  urination  which  occurs  in 

399 


400  MEDICAL  GYNECOLOGY. 

severe  attacks  of  hysteria,  due  to  tlie  conditions  just  men- 
tioned, the  same  thing  is  often  seen,  which  can  only  be  ac- 
counted for  by  the  state  of  the  nerves  which  govern  the 
action  of  the  bladder.  When  the  quantity  and  comi)osition 
of  the  urine  are  normal,  and  the  patient  can  retain  it  without 
pain  or  .distress  during  the  night,  but  has  to  pass  it  every 
hour  or  two  during  the  day,  it  may  safely  be  presumed  that 
the  trouble  is  functional  and  due  to  a  disordered  state  of  the 
nervous  system.  The  only  condition  which  resembles  this 
history  is  occasionally  seen  in  prolapsus  uteri,  the  patient 
being  free  from  trouble  while  reclining,  but  having  to  urinate 
frequently  when  in  the  erect  position. 

Hysterical  patients  frequently  suffer  from  retention  of 
urine.  Some  of  them  complain  for  a  time  of  difficulty  in 
emptying  the  bladder,  and  finally  fail  to  do  so  altogether. 
At  other  times  they  suddenly  find  that  they  can  not  urinate. 

There  are  conflicting  views  regarding  the  cause  of  this  re- 
tention, some  believing  that  such  xDatients  can  not  urinate,  and 
others  that  they  will  not.  Those  who  believe  that  the  trouble 
is  feigned  and  not  real  do  so  on  the  ground  that  in  this  mor- 
bid state  of  the  nervous  system  the  patients  enjoy  catheteri- 
zation, which  would  be  distressing  to  any  one  of  healthy  mind 
and  body.  Others  claim  that,  in  the  extreme  sexual  excite- 
ment which  occurs  in  some  cases  of  hysteria,  the  chronic 
erection  of  the  clitoris  exerts  pressure  upon  the  urethra. 
The  fact  is,  both  classes  are  found  in  practice.  There  are 
those  who  complain  of  retention  when  they  know  that  the 
doctor  will  use  the  catheter,  but  they  can  urinate  easily  when 
they  please.  Others  I  have  seen  who  were  suffering  from  ex- 
cessive and  painful  distention  of  the  bladder,  and  would 
have  gladly  relieved  themselves  if  they  could. 

The  following  case  is  rather  typical  of  one  class  :  A  single 
lady,  of  the  sensitif  class,  at  times  could  urinate  very  well, 
at  others  was  obliged  to  try  repeatedly  before  she  succeeded. 
She  was  a  lady  of  high  culture  and  liberal  education,  but  was 
not  agreeably  occupied,  and  hence  she  had  much  time  for 
introspection. 


FUNCTIONAL   DISEASES   OP   THE   BLADDER.  40I 

She  called  her  physician,  who  prescribed  remedies,  but 
finding  that  they  did  not  give  her  relief,  made  an  examination 
of  the  pelvic  organs,  but  could  find  no  cause  for  her  inability 
to  urinate  with  facility. 

Soon  after  she  was  taken  with  complete  retention,  which 
was  relieved  by  the  catheter.  This  continued  for  weeks,  re- 
quiring the  doctor  to  visit  her  three  times  a  day,  and  occa- 
sionally at  night,  to  pass  the  catheter.  For  some  reason, 
which  was  not  very  evident,  and  could  hardly  be  due  to  weak- 
ness or  suffering,  she  remained  in  bed  most  of  the  period  dur- 
ing which  the  catheter  was  used.  Becoming  weary  of  such 
close  attention,  the  doctor  tried  letting  her  wait,  to  see  if  a 
full  distention  of  the  bladder  would  have  any  good  effect. 
This  caused  her  so  much  pain  that  the  doctor  felt  somewhat 
mortified  at  his  want  of  feeling  in  permitting  her  to  suffer. 
During  this  time  he  had  tried  a  number  of  remedies,  but 
without  effect. 

At  this  stage  of  the  history  I  was  called  in  consultation, 
but  could  find  no  evidence  of  any  organic  disease,  local  or  gen- 
eral, and  the  urine  was  normal.  I  suggested  to  the  attending 
physician  that  the  trouble  was  hysteria,  but  he  assured  me 
that  she  was  singularly  free  from  all  evidences  of  that  affec- 
tion ;  indeed,  he  had  found  her  remarkably  calm  and  sensi- 
ble, and  very  free  from  nervousness  of  every  kind.  I  still 
held  to  the  diagnosis  of  hysteria,  and  advised  full  doses  of 
bromide  of  potassium  and  a  sitz  bath  when  she  desired  to 
urinate.  I  also  recommended  that  she  should  go  to  Saratoga 
and  drink  Hathorn  water.  She  did  this  ;  the  water  gave  her 
diarrhoea,  and  her  retention  was  immediately  relieved. 

Frequent  Urination  due  to  Hysteria  is  even  Commoner  than  Reten- 
tion.— I  remember  a  lady,  twenty-three  years  of  age,  enjoying 
good  general  health  and  living  in  very  easy  circumstances, 
who  had  some  disappointment  which  caused  her  much  dis 
tress.  She  had  faintings  of  a  mild  character,  which  alarmed 
her  mother  and  called  forth  much  sympathy.  About  this 
time  she  began  to  suffer  from  frequent  urination.  This  did 
not  yield  to  the  treatment  employed  by  the  family  physician. 


402  MEDICAL  GYNECOLOGY. 

and  she  was  brought  to  my  office  for  advice.  Her  health  was 
excellent,  but  she  was  greatly  annoyed  by  this  frequent  uri- 
nation. The  urine  was  normal,  except  at  times,  when  it  was  of 
a  very  light  color.  She  could  sleep  all  night  without  being 
disturbed ;  if  by  chance  she  did  not  go  to  sleep  immediately 
on  retiring,  she  was  obliged  to  micturate  every  few  minutes, 
and  if  she  was  awakened  in  the  night  she  had  to  do  so  many 
times  before  she  could  sleep  again. 

Any  little  mental  excitement,  such  as  going  to  church  or 
to  the  theater,  would  aggravate  the  trouble,  so  that  she  had 
to  give  up  all  public  duties  and  pleasures.  Systematic  exer- 
cise and  occupation,  cold  baths,  bromide  of  sodium,  and  a 
full  assurance  on  my  part  that  she  would  soon  recover,  helped 
her  greatly.  She  was  commanded  in  a  very  decided  way  to 
resist  the  inclination  to  such  frequent  urination,  and  obeying 
orders  recovered  completely. 

I.  DERANGEMENTS  OF  FUNCTION  DUE   TO  DISEASES  OF  THE 
NUTRITIVE   AND   NERVOUS    SYSTEMS. 

This  class  naturally  subdivides  itself  into — 

First.  Derangements  occurring  in  both  acute  and  chronic 
diseases.  Second.  Derangements  due  to  consequent  abnor- 
mal conditions  of  the  urine. 

First.  Of  the  derangements  which  occur  in  the  course  of 
acute  diseases,  such  as  retention  and  incontinence  of  urine 
and  frequent  urination,  nothing  more  than  the  mere  mention 
is  necessary.  They  rarely  require  any  treatment,  except  pos- 
sibly in  the  case  of  retention,  when  catheterization  is  to  be 
employed,  and  they  cease  as  soon  as  the  acute  stage  is  passed. 
Those  derangements,  however,  which  are  due  to  chronic  affec- 
tions of  the  nutritive  and  nervous  systems  are  more  perma- 
nent, and  often  tax  the  resources  of  the  physician  to  the 
utmost.     The  two  most  important  are — 

(a)  Paralysis  of  the  bladder. 

(5)  Incontinence  of  urine. 

Paralysis  of  the  Bladder. — This  trouble  has  also  been  de- 
scribed under  the  names  of  weakness  or  palsy  of  the  bladder 


FUNCTIONAL  DISEASES  OF   THE  BLADDER,  403 

and  vesical  atony.  It  occurs  in  two  forms  :  first,  from  causes 
residing  in  the  organ  itself  ;  secondly,  from  those  due  to  out- 
side influences.  As  affections  in  the  first  form  will  be  fully 
described  in  another  place,  I  shall  here  simply  mention  them. 
They  are :  fatty  degeneration  and  atrophy  of  the  muscular 
walls  of  the  bladder,  a  common  cause  of  paralysis  of  this  vis- 
cus  in  old  women  ;  overstrain  of  the  muscular  structure  from 
prolonged  retention,  voluntary  or  involuntary  ;  displacements 
and  inflammations  of  neighboring  organs  affecting  its  position 
or  nutrition  ;  and  abdominal  and  pelvic  tumors. 

In  fevers  of  a  serious  type  the  power  of  nerve  conduction 
may  either  be  lost  or  impaired,  and  a  partial  or  total  vesical 
paralysis  result,  with  overdistention  and  dribbling  of  urine. 

The  second  form  is  due  to  influences  acting  from  without 
the  bladder,  and  includes  acute  and  chronic  meningitis  ;  apo- 
plexies of  the  brain  or  spinal  cord  ;  sopor  ;  delirium  ;  myelitis 
of  the  lower  part  of  the  spinal  cord  ;  inflammation  of  any  kind 
primarily  affecting  or  involving  in  its  results  either  the  lum- 
bar nerves  or  ganglia ;  endarteritis  deformans  of  the  pelvic 
arteries  ;  lumbar  or  renal  abscesses  ;  blows  or  falls  upon  the 
loins,  suprapubic  region,  or  head ;  shock  or  disease  of  the 
vesical  or  lumbar  nerves  from  the  prolonged  use  of  opium  or 
poisoning  by  it,  and  also  shock  due  to  overdistention  of  the 
organ  itself. 

Symptomatology. — Except  in  cases  of  injury  of  the  brain 
and  apoplexies,  the  invasion  of  the  disease  is  usually  very 
gradual.  This  is  especially  the  case  in  the  aged,  and  some- 
times, though  rarely,  in  young  people.  The  patient  first  ob- 
serves that  the  urine  is  expelled  from  the  bladder  wdth  less 
force  than  usual,  that  the  act  of  emptying  the  bladder  is 
more  slowly  accomplished,  and  that  after  a  time  the  organ  is 
unable  to  expel  its  contents  without  considerable  straining 
and  aid  from  the  abdominal  muscles.  At  a  later  date,  if  the 
disease  goes  on  unchecked,  the  stream  is  less  and  less  forcibly 
ejected,  intermits,  and  the  bladder,  after  much  straining,  is 
but  partially  emptied.  Finally,  partial  or  complete  retention 
follows. 


404  MEDICAL  GYNECOLOGY. 

The  female  bladder  seems  to  be  capable  of  more  distention 
than  that  of  the  male.  Lieven,  in  a  case  of  supposed  ovarian 
tumor,  removed  by  catheterization  about  nine  pints  of  urine 
from  a  woman  thirty-three  years  of  age.  The  fundus  of  this 
patient's  bladder  reached  as  high  as  the  ensiform  cartilage. 
I  once  saw  a  case  exactly  like  this,  except  that  the  bladder 
only  reached  to  about  two  inches  above  the  umbilicus.  More 
than  a  gallon  has  been  drawn  off  by  Hofmeier  and  others. 

A  j^eculiarly  interesting  experiment  bearing  upon  the  dila- 
tability  of  the  bladder  was  made  by  Budge.  He  found  that 
section  of  the  lower  part  of  the  spinal  cord,  when  the  bladder 
was  considerably  distended,  allowed  increased  reflex  action 
of  the  sjDhincter,  and  enormous  distention  then  took  place — 
even  more  than  could  be  produced  by  force  after  death.  This 
is  especially  interesting  in  relation  to  vesical  paralysis  and 
retention  due  to  injury  or  disease  of  the  lumbar  portion  of 
the  spinal  cord. 

In  some  cases  of  overdistention  the  resistance  of  the  sphinc- 
ter is  overcome  somewhat,  and  a  constant  dribbling  of  urine 
takes  place.  It  has  been  called  by  some  authors  incontinentia 
paradoxa.  These  instances  are  liable  to  be  mistaken  for  com- 
plete incontinence. 

In  rare  cases  rupture  of  the  bladder  may  take  place  ;  but 
more  commonly  dilatation  of  the  ureters  and  hydronephrosis. 
If  the  condition  of  vesical  distention  be  not  soon  relieved,  vesi- 
cal catarrh,  true  inflammation,  ulceration,  and  death  take 
place.  In  forms  due  to  injury  or  disease  of  the  spinal  cord 
(low  down)  there  seems  to  be  a  paralysis  or  peculiar  condition 
of  the  nerves  presiding  over  the  nutrition  of  the  vesical  mu- 
cous membrane,  and  destructive  changes  are  not  uncommon. 

Diagnosis. — The  diagnosis,  though  easy,  is  sometimes  not 
made,  owing  to  ignorance  or  careless  observation.  When 
called  to  a  case  where  there  is  supposed  distention  of  the 
bladder,  the  abdomen  should  first  be  examined  to  see  if  there 
are  signs  of  a  tumor,  and  then  a  catheter  should  be  passed,  if 
that  be  possible,  to  determine  whether  an  abnormal  amount 
of  urine  is  present.     If  this  is  so,  and  the  tumor  gradually 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  405 

subsides  as  the  urine  flows,  the  diagnosis  is  at  once  made. 
When,  however,  a  catheter  can  not  be  passed  into  the  viscus, 
fluctuation  should  be  sought  both  through  the  vagina  and  on 
the  surface  of  the  tumor.  If  the  diagnosis  be  still  obscure, 
the  aspirator  needle  should  be  passed  into  the  tumor  and  its 
fluid  contents  carefully  tested.  The  age  of  the  patient,  the 
duration  of  the  disease,  and  its  time  and  method  of  invasion 
will  aid  in  settling  the  question.  The  trouble  may,  however, 
occur  at  almost  any  age,  and  the  fact  that  a  little  urine  has 
been  passed  at  short  intervals  will  tend  to  deceive. 

In  the  early  stages  of  the  disease  an  idea  can  be  gained  as 
to  its  progress  by  carefully  noting  the  amount  of  urine  i3assed 
at  each  micturition,  the  amount  passed  in  twenty-four  hours, 
the  length  of  intervals  between  each  act,  the  force  of  the 
stream,  whether  the  bladder  is  fully  or  but  partially  emptied, 
and  whether  the  stream  intermits.  The  urine  should  be  ex- 
amined often,  else  cystitis  may  get  a  firm  foothold  before  its 
existence  is  recognized.  In  drawing  off  the  urine  for  testing 
or  other  purposes,  the  catheter  should  be  surgically  clean. 

Incontinentia  paradoxa  must  be  differentiated  from  incon- 
tinence due  to  mechanical  causes,  such  as  abnormal  urine  or 
the  pressure  of  neighboring  organs  upon  the  bladder. 

Prognosis. — If  the  disease  be  uncomplicated,  the  prognosis 
is  favorable.  Paralysis  of  the  organ  accompanying  the  fevers, 
dysentery,  peritonitis,  and  the  like,  usually  disappears  with 
the  cure  of  the  original  disease.  If  the  paralysis  be  accom- 
panied by  disease  of  the  bladder  walls,  or  if  it  occurs  in 
weak,  debilitated  constitutions,  or  has  been  of  long  dura- 
tion, or  occurs  in  old  age,  the  prognosis  is  unfavorable.  A 
cure,  if  effected  at  all,  will  be  only  after  long  and  tedious 
treatment.  When  due  to  centric  causes,  or  to  serious  spinal 
disease  or  injury,  or  when  it  occurs  in  old  people,  or  with 
meningitis,  or  with  systemic  trouble,  the  prognosis  is  very 
grave  indeed. 

Causation. — Deranged  innervation  due  to  the  central  le- 
sion already  mentioned,  either  cerebral  or  spinal,  may  be 
regarded  as  the  principal  cause  of  this  affection.     If  the  pa- 


406  MEDICAL   GYXECOLOGY. 

ralysis  has  been  of  long  duration,  nutritive  changes  may  occur 
in  the  bladder ;  but  as  these  will  be  discussed  under  the  appro- 
priate head,  I  need  say  nothing  of  them  here. 

Treatment. — In  all  cases  where  there  is  fear  of  vesical  dis- 
tention the  bladder  should  be  emptied  at  stated  intervals. 
By  way  of  helping  the  patient  to  pass  water  herself,  hot  hip- 
baths and  fomentations  over  the  bladder  may  be  tried.  The 
sound  of  water  falling  from  one  vessel  into  another  often  ac- 
complishes the  same  result.  If  these  means  do  not  succeed, 
the  catheter  must  be  used. 

Attention  may  be  called  here  to  a  very  important  prac- 
tical point  in  connection  with  the  use  of  the  catheter.  When 
the  bladder  has  become  very  much  distended  it  can  not  be 
thoroughly  emptied  unless  pressure  is  made  upon  the  abdom- 
inal walls ;  if  this  pressure  is  made  while  the  catheter  is  in 
the  bladder,  and  then  discontinued,  air  will  be  drawn  through 
the  catheter  into  the  bladder,  and  decomposition  of  the  urine 
will  thus  be  favored. 

Marked  distention  can  usually  be  relieved  by  the  catheter. 
In  some  examples,  however,  the  bladder  rises  up  into  the  ab- 
domen and  puts  the  urethra  upon  the  stretch,  thus  changing 
the  direction  of  its  axis  from  the  normal  to  one  from  below 
directly  upward,  the  canal  being  nearly  parallel  to  the  pos- 
terior surface  of  the  pubic  symphysis.  In  these  instances 
passing  the  catheter  will  tax  the  skill  somewhat.  Great  care 
must  be  taken  to  avoid  injuring  the  urethra. 

In  emptying  a  greatly  distended  bladder,  a  binder  should 
be  applied  to  the  abdomen  and  tightened  gradually  as  the 
urine  flows.  It  is  not  safe  to  draw  off  ail  the  urine  at  once ; 
it  is  better  to  take  away  about  half,  and  then  after  a  time 
to  draw  off  more,  until  the  organ  is  empty.  Syncope  and  even 
death,  which  are  said  to  have  occurred  in  these  cases  after 
rapid  emptying  of  the  organ,  are  probably  due  to  the  sudden 
removal  of  the  pressure  on  the  abdominal  organs,  which  so 
deranges  the  circulation  as  to  produce  these  serious  results. 
The  sudden  removal  of  pressure  (which  causes  anaemia)  from 
the  vesical  walls  allows  intense  congestion,  and,  the  vesical 


FUNCTIONAL   DISEASES   OP  THE  BLADDER.  407 

walls  being  paralyzed,  catarrh  and  cystitis  result.     Therefore 
a  distended  bladder  should  be  emptied  slowly. 

When,  for  any  reason,  a  catheter  can  not  be  introduced 
into  the  bladder,  hot  hip-baths  should  be  again  tried,  and 
opium  given  in  sufficient  amount  to  relieve  pain  and  any  spas- 
modic action  that  may  exist.  If  after  this  there  is  failure  to 
enter  the  bladder  (and  it  is  only  in  very  rare  cases  that  this 
occurs),  recourse  should  be  had  to  the  aspirator,  and,  after 
having  piyictured  the  bladder,  the  urine  should  be  drawn 
slowly  and  carefully  in  the  manner  already  described. 

In  the  commencement  of  vesical  paralysis  and  when  in- 
continentia paradoxa  exists  or  has  existed,  the  patient  should 
be  taught  to  use  the  catheter  herself  several  times  daily  until 
the  vesical  power  returns.  It  is  of  the  utmost  importance 
that  the  catheter  be  clean.  After  each  time  that  it  is  used  it 
should  be  thoroughly  rinsed  in  a  chlorine  solution,  or  boiled 
for  fifteen  minutes.  A  vesical  catarrh  is  undoubtedly  pro- 
moted by  foul  catheters,  and  this  is  especially  so  in  hos- 
pitals, where  the  same  instrument  is  often  used  on  a  number 
of  patients. 

In  cases  of  paralysis,  commenced  or  established,  the  effect 
of  the  induced  electric  current  may  be  tried.  One  pole  thor- 
oughly insulated  up  to  the  point  should  be  placed  in  the 
bladder  and  the  other  over  the  pubic  symphysis  and  loins, 
letting  the  current  flow  in  various  directions,  through,  over, 
and  into  the  affected  organ.  The  German  authors — especially 
Winckel,  by  whom  this  method  is  highly  recommended  in 
this  and  like  comjplaints — say  that  the  sitting  should  last 
about  five  minutes. 

Forcibly  distending  the  urethra  and  washing  out  the 
bladder  with  a  solution  containing  salicylic  acid  have  been 
tried  and  recommended.  I  can  not  see  the  expediency  of 
this  unless  vesical  catarrh  exists  ;  and  even  then  washing 
must  be  done  gently  and  carefully,  and  without  previous 
dilatation  of  the  urethra. 

Attention  should  be  paid  to  the  general  health.  The 
food  should  be  good  and  nourishing,   and  the  alimentary 


408  MEDICAL  GYNECOLOGY. 

canal  kept  in  a  proper  condition  to  receive  and  digest  it. 
Wines  (especially  champagne),  beer,  and  ale  may  be  of  use.  I 
can  at  least  say  if  stimulants  are  ever  given  in  diseases  of  the 
bladder  it  should  be  in  examples  like  these  now  under  con- 
sideration. These  patients  are  usually  more  comfortable  in 
the  standing  or  sitting  than  in  the  supine  posture.  As  they 
are  commonly  worse  in  winter  than  in  summer,  it  is  advisa- 
ble, if  the  case  is  chronic  and  the  patient  able  to  bear  trans- 
portation and  rich  enough  to  meet  the  expense,  to  send  her 
to  a  moderately  warm  climate  during  the  winter  months. 
This  will  apply  in  most  of  the  diseases  of  the  bladder. 

If  the  trouble  be  purely  atonic,  camphor  or  musk  may 
be  administered  internally.  Tincture  of  cantharides,  in  from 
five  to  twenty  drop  doses,  three  times  a  day,  has  been  recom- 
mended as  a  vesical  excitant.  I  can  not  indorse  its  use  with- 
out the  caution  that,  besides  the  tendency  to  irritate  the  kid- 
neys and  produce  congestion  and  nephritis,  it  may  induce  a 
severe  cystitis.  Furthermore  it  may  produce  serious  trouble 
without  causing  much  pain  to  give  warning  of  the  danger, 
because  the  paralysis  lessens  the  sensitiveness  of  the  bladder, 
so  that  destruction  of  tissue  may  occur  without  producing  the 
usual  pain  and  suffering. 

Strychnine  has  been  extensively  prescribed  in  this  com- 
plaint, and  with  good  results  in  some  cases.  Its  failure  to  do 
good  in  many  instances  is  undoubtedly  due  to  the  fact  that 
it  was  not  given  in  sufficiently  large  doses.  It  may  be  safely 
pushed  as  high  as  the  one  twentieth  of  a  grain  three  times 
a  day,  stopping  for  a  few  days  if  any  of  its  characteristic 
symptoms  appear.  It  has  also  been  used  hypodermically  in 
the  neighborhood  of  the  bladder. 

Ergot  has  been  found  serviceable  in  cases  where  the  pa- 
ralysis was  due  to  exposure  to  cold,  or  prolonged  retention 
from  any  cause.  The  fresh  powder  has  been  recommended, 
and  may  be  given  in  doses  of  from  eight  to  sixteen  grains  four 
or  five  times  daily.  It  is  more  pleasant,  and  probably  more 
effective,  to  give  its  equivalent  of  the  fluid  extract.  Aliers 
has  used  it  with  decided  success  in  cases  of  vesical  paralysis 


FUNCTIONAL  DISEASES  OP  THE  BLADDER.  409 

due  to  centric  troubles,  such  as  apoplexy,  and  has  prescribed 
as  much  as  forty-five  grains  in  the  twenty-four  hours.  It  is 
highly  spoken  of  also  by  Roth,  Jacksch,  and  others. 

Rutenberg  (Wiener  med.  Wochenschrift,  1875,  No.  37) 
has  recommended,  in  cases  where  there  is  destruction  of 
muscular  tissue  or  incurable  paralysis  from  any  cause,  that 
an  opening  be  made  into  the  bladder  just  above  the  pubic 
symphysis,  keeping  the  fistula  open  and  closing  the  urethra 
by  operative  procedures.  The  urine  can  thus  be  retained, 
unless  the  patient  bends  forward  and  downward  or  lies  upon 
her  abdomen.  A  urinal  would,  of  course,  be  necessary  to 
protect  the  j)atient. 

Paralysis  of  the  nerves  which  control  the  bladder  walls 
generally  causes  retention,  as  already  noticed.  Disease  of 
the  nerve  centers  which  preside  over  the  retaining  power  of 
the  bladder  produces  incontinence. 

There  are,  then,  two  opposite  results  or  derangements  of 
function  which  come  from  lesions  of  innervation  due  to  dis- 
ease of  the  difi'erent  portions  of  the  nerve  structures.  The  fol- 
lowing examples  are  of  the  latter  variety,  where  paralysis  of 
the  bladder  was  followed  by  incontinence  in  case  of  insanity. 

In  one,  the  insanity  had  existed  for  eight  months,  and  al- 
though at  first  violent,  was  now  mild,  indeed  rather  a  demen- 
tia. The  patient's  physician  had  observed  for  some  time  that 
her  bowels  were  obstinately  constipated,  and  the  nurse  noticed 
that  she  had  great  difficulty  in  evacuating  the  bladder.  She 
also  appeared  to  have  sojne  discomfort  in  that  region  ;  finally, 
went  for  over  twenty-four  hours  without  urinating,  and  then 
I  was  called  to  see  her.  I  found  the  bladder  greatly  distend- 
ed, and  yet  I  could  not  perceive  that  she  had  pain  or  tender- 
ness on  that  account.  The  catheter  was  employed,  and  three 
and  a  half  pints  of  urine  were  removed.  After  this  the  cath- 
eter had  to  be  used  twice  in  twenty-four  hours  for  five  weeks. 
During  this  time  the  customary  means  were  tried  to  restore 
the  function  of  the  bladder,  but  without  effect.  The  urine 
then  began  to  flow  constantly.  When  I  heard  of  this,  I  pre- 
sumed that  the  bladder  had  become  overdistended,  and  that 


410  MEDICAL  GYNECOLOGY. 

the  nurse  wlio  used  the  catheter  had  not  emptied  the  blad- 
der. This  I  found  was  not  so,  as  the  bladder  was  empty. 
The  incontinence  continued  until  the  patient  died  of  general 
paralysis. 

In  another  case  I  witnessed  paralysis  of  the  bladder  from 
cerebro-spinal  meningitis  in  a  girl  twelve  years  old  who  pre- 
sented the  usual  clinical  history  of  that  affection  until  the 
seventh  day  of  the  disease,  at  which  time  the  pain  had  sub- 
sided to  a  great  extent,  but  her  mind,  which  up  to  this  time 
had  been  clear,  began  to  wander.  Retention  of  the  urine 
was  noticed  by  her  nurse,  who  called  my  attention  to  the  fact. 
I  found  the  bladder  distended,  but  not  greatly  so.  She  was 
asked  if  she  did  not  desire  to  urinate,  but  answered  in  the 
negative,  so  far  as  I  could  understand  her.  The  catheter  was 
used,  and,  although  the  distention  was  not  great,  the  bladder 
did  not  contract  well,  so  that  abdominal  pressure  was  neces- 
sary to  make  the  urine  flow  through  the  instrument.  The 
use  of  the  catheter  was  necessary  for  some  time,  during  which 
she  improved  in  her  general  condition,  the  mind  becoming 
quite  clear.  She  then  began  to  express  at  times  a  desire  to 
urinate,  but  could  not  relieve  herself.  Four  days  later  she 
succeeded  in  doing  so,  but  did  not  completely  empty  the  blad- 
der. She  gradually  improved,  but  the  catheter  was  passed 
once  every  twenty -four  hours  for  a  week  longer.  The  desire 
to  empty  the  bladder  became  more  and  more  urgent,  and  she 
had  pain  in  the  urethra  in  urinating.  An  examination  of  the 
urine  at  this  time  showed  that  the  patient  had  cystitis — due, 
I  believe,  to  the  use  of  the  catheter.  The  cystitis  was  treated 
according  to  my  usual  methods,  and  resulted  in  a  good  re- 
covery. 

In  a  case  of  paralysis  of  the  bladder  from  progressive 
locomotor  ataxia  in  a  lady  who  had  been  affected  with  this 
malady  for  more  than  a  year,  retention  was,  of  course,  the 
leading  symptom.  There  was  some  decomposition  of  the 
urine,  but  nothing  else  to  distinguish  the  disorder  from  pa- 
ralysis of  the  bladder,  occurring  in  other  cases  of  disease  and 
injury  of  the  spinal  cord.     The  attendant  was  advised  to  use 


FUNCTIONAL  DISEASES  OP   THE   BLADDER.  ^H 

the  catheter  regularly,  and  to  wash  out  the  bladder  with  a 
solution  of  borax — one  drachm  of  borax  to  a  quart  of  warm 
water.  I  learned  subsequently  that  this  patient  had  inconti- 
nence of  urine  before  she  died. 

n.    DERANGEMENTS    DUE     TO    ABNORMAL    CONDITIONS    OF 

THE   URINE, 

The  bladder,  being  made  to  contain  urine  of  a  certain 
composition,  at  once  feels  and  responds  to  any  abnormity. 
If  the  change  in  character  is  only  occasional,  the  effects  are 
slight  and  of  short  duration  ;  but  if  the  abnormity  be  con- 
stant, or  nearly  so,  or  if  the  altered  urine  finds  a  hyper^s- 
thetic  surface  to  irritate,  the  results  are  more  annoying. 

Urine  which  is  too  acid,  or  alkaline  ;  too  limpid,  or  greatly 
concentrated,  acts  somewhat  like  a  foreign  body — it  irritates, 
and  the  bladder  inclines  to  expel  it. 

Deposits  of  any  of  the  urinary  salts  in  the  viscus  may 
produce  an  irritable  condition,  and,  if  unchecked,  lead  to 
organic  disease  of  the  bladder.  Uric  acid,  in  large  or  small 
crystals,  in  little  masses,  forming  gravel  and  minute  calculi, 
the  amorphous  urates,  the  triple  and  amorphous  phosphates 
(these,  as  a  rule,  however,  occurring  only  in  decomposition 
of  the  urine),  and  oxalate  of  lime,  may  give  rise  to  consider- 
able trouble.  There  are  some  other  deposits,  such  as  cystine, 
that  are  of  such  rare  occurrence  that  they  need  not  be  men- 
tioned in  this  list.  In  any  of  these  cases,  but  especially 
when  there  is  a  deposit  of  uric  acid,  one  or  two  things 
may  result :  first,  a  real  excess  of  the  salt  in  the  urine  ; 
and,  second,  a  condition  of  the  secretion,  where,  whether 
the  amount  of  salt  present  be  normal,  or  less  or  more  than 
normal,  it  will  be  precipitated  in  the  bladder.  In  order 
to  treat  the  case  properly  these  results  must  be  borne  in 
mind. 

As  an  example  of  the  first  some  forms  of  dyspepsia  may 
be  mentioned,  when,  owing  to  a  defect  in  either  primary  or 
secondary  assimilation,  the  salt  or   salts  are  eliminated  by 

the  kidneys  greatly  in  excess.     Here  a  normal  or  even  an 

27 


412  MEDICAL  GYNECOLOGY. 

abnormal  amount  of  water  in  tlie  secretion  could  not  hold 
them  in  solution,  and  they  are  consequently  precipitated. 

As  an  example  of  the  second  may  be  taken  cases  of 
hepatic  disease,  in  which,  although  the  uric  acid  is  elimi- 
nated in  abnormally  small  amount,  it  is  precipitated  on  ac- 
count of  deficiency  of  water,  excessive,  acidity,  and  possibly 
by  absorption  of  the  watery  element  of  the  urine  while  in 
the  bladder. 

In  some  cases,  with  an  excess  of  salts  there  may  be  ex- 
cessive acidity  and  lack  of  water.  Some  forms  of  dyspepsia 
are  notable  examples  of  this,  and  as  low  nerve  condition 
frequently  accompanies  these  disorders,  the  abnormal  urine 
meets  in  the  bladder  with  an  irritable  mucous  membrane. 
In  these  instances  the  acidity  is  quite  as  hurtful  as  the 
deposit. 

Deposits  of  oxalate  of  lime  in  the  bladder  are  not  >  so 
common  (except  in  lime-water  regions)  as  those  of  uric  acid. 
In  cases  of  the  persistent  deposit  of  oxalate  of  lime  in  the 
urine,  known  as  oxaluria,  there  is  marked  irritability  of  the 
bladder.  This  has  been  ascribed  by  some  to  the  presence  of 
minute  octahedra  of  this  salt  irritating  the  mucous  mem- 
brane. It  is  more  than  likely,  however,  that  the  derange- 
ment of  the  general  nervous  system,  always  existing  in  these 
cases,  stands  as  a  propter  rather  than  a  p)ost  hoc,  and  that 
the  bladder  difficulty  is  but  a  local  manifestation  of  the  gen- 
eral disease,  and  consequently  a  pure  neurosis.  That  the 
urine  in  oxaluria  does  possess  irritant  properties  there  is 
little  doubt,  but  it  is  hardly  likely  that  the  symptoms  oc- 
curring here  would  be  produced  unless  there  was  already  an 
abnormal  condition  of  the  vesical  mucous  membrane. 

Many  authors  hold  that  the  high  specific  gravity  of  a 
single  specimen  of  urine  must  not  be  taken  as  an  evidence  of 
concentration,  or  the  low  gravity  of  excessive  limpidity  of 
the  twenty-four  hours'  urine.  This  is  very  true  in  regard  to 
the  total  amount  passed  in  a  day  ;  but,  as  the  bladder  has 
to  do  only  with  the  urine  in  it  at  that  time,  it  will  be  well 
in  these  cases  to  examine  several  specimens  in  a  day,  rather 


FUNCTIONAL  DISEASES  OP  THE  BLADDER.  413 

than  to  depend  for  information  on  tlie  reaction  of  the  total 
amount  of  urine  passed. 

Urine  may  irritate  the  same  patient  at  one  time  from  be- 
ing too  limpid,  and  at  another  time  from  being  too  highly 
concentrated.  These  variations  must  be  carefully  watched 
and  treated.  A  bladder  that  is  irritable  at  all  times,  and 
with  urine  of  varying  reactions,  may  be  set  down  as  one 
affected  with  a  pure  neurosis,  if  no  organic  cause  be  found, 
for  the  urine  could  not  work  the  mischief  continually  if 
normal  at  certain  periods. 

Symptomatology. — Patients  suffering  from  this  affection 
usually  complain  of  frequent  urination  and  vesical  tenesmus. 

In  some  instances  there  is  smarting  pain  in  the  urethra 
during  and  for  some  time  after  the  passing  of  water,  and 
there  is  a  sense  of  heat  in  the  bladder  and  a  desire  to  uri- 
nate which  are  not  fully  relieved  when  the  bladder  is  empty. 
This  last-named  symptom  belongs  more  especially  to  those 
cases  in  which  the  urine  salts  are  in  excess.  When  the 
urine  is  defective  in  the  salts — that  is,  when  the  urine  is 
limpid— the  only  symptom  present  is  frequent  urination.  It 
will  be  observed  that  these  indications  are  the  same  as  those 
presented  in  a  variety  of  affections,  and  hence  can  not  be 
depended  upon  in  making  a  diagnosis. 

Diagnosis. — The  diagnosis  must  be  made  by  excluding 
all  other  conditions  which  give  rise  to  this  derangement  of 
function,  by  repeated  examinations  of  the  urine,  which  will 
show  its  abnormal  state. 

Prognosis. — The  relief  of  this  class  of  patients  will  de- 
pend upon  the  possibility  of  correcting  the  constitutional 
affections  which  produce  the  pathological  state  of  the  urine. 
If  the  abnormities  of  the  urine  persist  for  a  long  time, 
cystitis  and  urethritis  may  be  produced.  I  am  sure  that  I 
have  seen  cystitis  which  could  be  traced  to  long-continued 
abnormal  states  of  the  urine. 

Causation. — In  discussing  the  pathology  of  this  class  of 
functional  derangements  the  causes  which  produce  them  have 
been  fully  brought  out,  so  that  they  need  not  be  repeated  here. 


414  MEDICAL  GYNECOLOGY. 

Treatment. — In  cases  of  concentration  of  the  urine  due 
to  acute  febrile  action,  the  patient  should  be  liberally  sup- 
plied with  cooling  drinks  ;  and  as  in  these  affections  the 
urine  is  generally  too  acid,  the  slightly  alkaline,  effervescing 
waters  will  be  found  useful. 

In  digestive  troubles,  vrith  excessive  acidity  or  saline  de- 
posit, attention  should  be  paid  to  diet,  bathing,  and  regu- 
larity of  the  bowels,  as  well  as  to  the  taking  of  a  proper 
amount  of  exercise.  Where  deposits  of  uric  acid  take  place 
there  is  usually  some  defect  in  either  primary  or  secondary 
assimilation.  This  should  be  sought  out  and  remedied.  In 
excessive  acidity  with  deposits  of  uric  acid,  the  alkaline 
carbonates  act  in  a  double  way— first  by  neutralizing  the 
acidity  of  the  urine,  and  second  by  acting  on  the  liver  to 
lessen  the  amount  of  uric  acid  produced.  The  follovdng 
is  a  very  pleasant  and  efficient  prescription  in  these  cases  : 

;p,  Potassii  bicarbonatis, 

Potassii  citratis aa   3  ss. ; 

Syrupi  simplicis 3  iv. 

M.  Sig.  :  Take  one  drachm  in  half  a  tumbler  of  water, 
adding  two  drachms  of  lemon-juice.    Drink  while  effervescing. 

The  late  Prof.  Armour  gave  some  very  excellent  advice 
regarding  the  management  of  such  cases,  which  I  will  repro- 
duce in  his  own  words  : 

"When  the  urine  is  acid  in  any  of  the  forms  of  cystic 
irritation,  great  relief  is  experienced  from  the  use  of  alkalies, 
especially  when  administered  in  an  infusion  of  buchu.  I 
regard  buchu  as  a  remedy  of  undoubted  efficacy  in  all  cases 
of  vesical  irritability.  It  seems  to  possess  similar  properties 
over  the  urinary  tract  that  bismuth  does  over  the  intestinal, 
and  is  an  admirable  vehicle  in  which  to  administer  the  va- 
rious alkalies.  The  citrate  of  potash  with  buchu  is  an  excel- 
lent combination  where  we  desire  the  joint  action  of  these 
remedies.  The  liquor  of  potash,  the  bicarbonate  and  the 
iodide  of  the  same,  also  possess  a  high  degree  of  utility  in 
the  class  of  cases  referred  to,  and  their  therapeutic  action  is 


FUNCTIONAL  DISEASES  OP  THE  BLADDER.  415 

certainly  never  disturbed  by  administering  them  in  an  infu- 
sion of  buchu. 

"In  irritable  conditions  of  the  bladder  associated  with  a 
gouty  and  lithic-acid  diathesis  the  carbonate  of  lithium  is 
a  remedy  of  undoubted  eificacy.  It  perhaps  excels  the  prep- 
arations of  potash  in  rendering  uric  acid  and  the  urates 
soluble." 

The  following  is  the  formula  of  a  prescription  which 
answers  well : 

^  Lithise  carbonatis 3  ij ; 

Acidi  benzoici 3  iij ; 

Sodii  boratis. 3  j  ; 

Aquse  dest ^  iv. 

M.     Sig.  :  One  teaspoonf  ul  in  a  large  glass  of  water. 

Limpid  urine  is  usually  due  to  some  general  nervous 
trouble  or  cerebral  disease.  In  such  instances  treatment 
should  be  directed  to  the  original  disease. 

Deposits  of  amorphous  or  triple  phosphates  are  rare 
unless  there  is  some  organic  disease  of  the  bladder.  Where 
the  deposits  are  not  due  to  decomposition,  some  decided 
nerve  trouble  is  usually  present,  and  here,  as  in  limpidity, 
the  attention  must  be  turned  to  treatment  of  the  general 
trouble. 

In  oxaluria  attention  must  be  paid  to  the  moral,  mental, 
and  physical  condition,  and  time  must  not  be  wasted  in  treat- 
ing mere  symptoms.  In  the  way  of  medication,  the  follow- 
ing prescription  is  looked  upon  by  many  as  almost  specific 
in  these  cases : 

5'  Acidi  nitro-muriatici  diluti. 3  v-vj ; 

Tincturse  nucis  vomicae 3  iij ; 

Olei  gaultherise iTixiJ ; 

Aquae ad   §iv. 

M.     Sig. :  One  drachm  in  water  before  each  meal. 

In  some  examples  the  pure  non-diluted  acid,  freshly  made 
up,  acts  better  than  the  dilute.     It  should  be  given  in  smaller 


416  MEDICAL  GYNECOLOGY. 

doses,  of  course,  than  the  dilute,  and  in  plenty  of  water  at 
the  time  of  taking  it.  In  all  cases  of  urinary  deposits  pure 
water  should  be  freely  taken,  and  the  greatest  attention  paid 
to  general  hygiene  and  to  mental  and  moral  surroundings. 

Many  of  the  slightly  alkaline  mineral-spring  waters  will 
be  found  of  use,  acting  gently  on  the  liver,  flushing  the  kid- 
neys and  urinary  organs,  and  slightly  relaxing  the  bowels. 
A  considerable  quantity  should  be  taken  in  the  course  of  the 
day  when  the  stomach  is  empty. 

The  following  cases  show  derangement  of  function  from 
this  cause : 

I  found  irritation  of  the  bladder  from  abnormal  urine  in  a 
patient  forty-three  years  old,  large  and  stout,  who  had  men- 
struated scantily  for  several  months,  and,  as  the  flow  dimin- 
ished in  quantity  and  duration,  gained  in  flesh  but  not  in 
strength.  She  had  a  very  good  ajDpetite  and  lived  weU,  but 
did  not  feel  in  her  usual  health.  She  became  conscious  of  a 
gradual  disinclination  to  mental  and  physical  activity,  and 
backache,  headache,  and  wandering  pains  here  and  there, 
occasionally  annoyed  her.  After  these  symptoms  had  con- 
tinued for  a  time  urination  became  more  frequent  and  at 
times  slightly  painful.  She  noticed  also  that  there  was  a 
sediment  in  the  urine. 

These  symptoms  caused  her  to  seek  advice  from  the  fear 
that  she  had  Bright's  disease.  She  was  found  to  possess  a 
very  good  organization  and  there  was  no  organic  disease 
of  any  kind  present.  All  the  evidences  of  excrementitious 
plethora  were  well  expressed  in  the  abundant  adipose  tissue, 
coated  tongue,  constipation,  muddy  appearance  of  the  eyes, 
full  slow  pulse,  shortness  of  breath  on  exertion,  depression  of 
spirits,  disposition  to  sleep,  and  at  times  sleeplessness.  The 
urine  was  examined,  and  found  to  be  slightly  alkaline,  its 
specific  gravity  was  1030,  and  there  was  neither  albumin  nor 
casts.  The  salts  of  the  urine  were  in  excess,  but,  as  a  quan- 
titative analysis  was  not  made,  its  exact  composition  was  not 
obtained.  The  diagnosis  of  general  excrementitious  plethora 
from  imperfect  elimination  was  made,  and  the  frequent  uri- 


FUNCTIONAL   DISEASES  OP  THE   BLADDER.  417 

nation  was  attributed  to  the  abnormal  condition  of  the  urine. 
Ten  grains  of  pilulse  hydrargyri  and  one  grain  of  ipecac 
were  given  at  bedtime  and  a  Seidlitz  powder  an  hour  be- 
fore breakfast  the  next  morning.  This  was  repeated  in  five 
days. 

The  quantity  of  food  was  diminished ;  she  had  been  tak- 
ing extra  diet  to  make  her  stronger.  Milk  was  the  chief  article 
permitted,  with  a  very  little  animal  food  once  a  day.  A  Turk- 
ish bath  was  taken  twice  a  week  and  out-of-door  exercise 
gradually  increased.  The  bowels  were  kept  rather  free  by  giv- 
ing a  dose  of  Congress  water  an  hour  before  breakfast  every 
morning.  Under  this  treatment  she  improved  in  every  way, 
the  irritation  of  the  bladder  subsided,  and  did  not  return, 
and  the  urine  became  normal. 

Frequent  Urination  from  Abnormal  Urine. — I  also  found  one 
case  especially  that  exemplified  this  form  of  trouble  :  that  of 
an  unmarried  lady,  thirty  years  old,  of  good  constitution, 
very  ambitious  and  energetic,  who  overtaxed  herself  during 
the  winter,  and  toward  the  end  of  the  season  began  to  suffer 
from  frequent  urination  and  a  sense  of  burning  heat  in  the 
bladder  and  urethra  following  the  act.  After  a  time  these 
symptoms  became  very  annoying,  and,  as  she  was  a  nervous, 
sensitive  person,  she  suffered  quite  severely.  She  was  in  ill 
health,  her  appetite  was  poor  and  her  digestion  impaired  ; 
she  was  constipated,  and  suffered  from  rheumatic  pains  in 
the  joints  and  in  the  back  of  the  neck.  In  short,  her  case 
gave  a  fairly  good  history  of  dyspepsia  and  neurasthenia  plus 
the  irritation  of  the  bladder,  which  was  her  chief  source  of 
discomfort.  The  urine  was  diminished  in  quantity,  dark  in 
color,  very  acid,  and  of  high  specific  gravity  ;  no  albumin  or 
casts  were  found.  She  had  been  quite  free  from  any  affections 
of  the  pelvic  organs,  the  present  disturbance  of  the  bladder 
being  the  only  suffering  she  had  ever  had  in  that  respect. 

My  first  impression  was  that  she  had  cystitis,  but  there 
were  no  products  of  inflammation  found  in  the  urine,  and 
therefore  the  diagnosis  was  made  as  stated  above.  Pepto- 
nized milk  was  ordered,  with  raw  eggs,  and,  in  addition,  bar- 


418  MEDICAL  GYNECOLOGY. 

ley  gruel,  clear  soups,  and  bread.  Two  drops  of  liquor  am- 
monia in  a  wineglass  of  water  were  given  every  two  hours 
until  tlie  urine  became  less  acid  in  reaction.  Her  bowels 
were  kept  regular  by  small  doses  of  Rochelle  salts  and  cream 
of  tartar  taken  in  the  morning. 

Rest  was  insisted  upon,  and  massage  ordered  every  third 
day.  As  soon  as  the  urine  became  less  acid  and  dense,  she 
obtained  some  relief,  but  was  not  restored  to  her  usual  condi- 
tion. It  was  not  until  her  general  health  had  been  improved 
that  the  urine  became  normal  and  the  irritation  of  the  bladder 
finally  left.  An  interesting  point  in  the  treatment  was  ob- 
served :  for  a  time  she  was  partially  relieved  by  the  alkaline 
remedies,  but  when  she  ceased  taking  them  the  irritation  of 
the  bladder  returned. 

When  her  general  health  was  restored  by  rest  and  tonics 
the  urine  became  normal,  and  the  irritation  of  the  bladder 
disappeared  entirely.  Cases  of  this  kind  are  sometimes 
helped  by  drinking  lithia  water  between  meals. 

Baruria — as  its  name  indicates,  an  abnormally  high  specific 
gravity  of  the  urine — is  not  very  common.  Dr.  Samuel  West 
describes  it  appearing  in  a  woman  who  after  "catching  cold" 
had  pains  and  aches  in  her  limbs,  which  became  severe  enough 
after  a  week  to  keep  her  in  bed.  These  pains  continued,  and 
there  was  swelling  of  the  Joints.  The  temperature  was  100°, 
and  she  perspired  freely.  The  urine  had  a  specific  gravity 
of  1040,  and  yielded  copious  crystals  of  nitrate  of  urea,  with 
nitric  acid.  Her  appetite  had  been  for  some  days  very  bad, 
and  in  the  hospital  she  took  but  little  milk  or  beef  tea.  For 
two  days  the  condition  of  the  urine  was  the  same,  and  the 
percentage  of  urea  5*1.  This  percentage  gradually  fell  to 
normal,  and  as  it  did  so  all  the  patient's  symptoms  disap- 
peared. The  case  was  regarded  as  one  of  baruria.  The 
account  of  the  case  given  by  Front  was  summarized  and  com- 
pared with  the  present  one,  and  reference  was  made  to  other 
authors,  by  some  of  whom  the  existence  of  the  affection  was 
questioned,  while  by  others  it  was  not  referred  to  at  all,  A 
somewhat  similar  case,  the  result  of  overfeeding  and  consti- 


FUNCTIONAL   DISEASES   OF   THE  BLADDER.  419 

pation,  lias  been  described,  in  which  like  symptoms  were  as- 
sociated with  a  high  percentage  of  urea,  and  disappeared 
when  the  amount  became  normal. 

ni.  DERANGEMENTS  DUE   TO   MALARIA. 

These  functional  derangements  are  not  easily  classified, 
owing  to  the  fact  that  the  materies  morhi  of  malaria  acts  on 
the  nervous  system,  the  blood,  and  also  by  changing  the 
character  qf  the  urine.  All  these  causes  act  together  to  de- 
range the  function  of  the  bladder. 

Previous  to  my  own  work  on  this  subject  there  was  little 
if  anything  known  or  said  about  it.  As  1  have  observed  this 
disorder,  the  bladder  and  urethra  are  usually  both  affected, 
but  I  do  not  consider  the  disease  inflammatory  in  character. 
Symptoms  of  malaria  are  usually  present,  but  not  necessarily 
chills  and  fever.  On  the  contrary,  I  believe  that  I  have  ob- 
served the  affection  more  frequently  in  remittent  than  in  in- 
termittent fever,  and  very  often,  where  the  constitutional 
indications  were  not  more  than  slight  derangements  of  the 
digestive  organs,  with  moderate  elevation  of  temperature  in 
the  after  part  of  the  day. 

The  symptoms  vary,  but  usually  are  as  follows :  The  pa- 
tient complains  of  frequent  desire  to  urinate,  and  of  some 
-vesical  tenesmus  ;  severe  burning  pain  on  passing  water,  with 
stinging  and  burning  in  the  urethra  after  the  act.  The 
history  of  such  cases  resembles  acute  urethritis  so  far  as 
the  abruptness  of  the  attack  and  the  tenderness  and  pain  of 
the  urethra  are  concerned,  but  there  is  usually  no  discharge, 
or,  at  least,  very  little.  As  a  rule,  the  suffering  is  greatest 
in  the  afternoon  and  early  part  of  the  night.  Under  proper 
treatment  the  disease  disappears  as  promptly  as  it  comes. 

Since  I  called  attention  to  this  subject  Dr.  Leake  (paper 
read  before  the  Texas  State  Medical  Association)  reports  his 
experience.  He  says,  in  part:  "The  case  is  one  exemplify- 
ing the  effect  that  the  malarial  poison  may  exert  upon  the 
female  bladder ;  an  observation  which  may  appear  common- 
place, since,  as  is  well  known,  it  has  not  escaped  mention  by 


4:20  MEDICAL  GYNECOLOGY. 

Prof.  Skene,  in  his  excellent  work  on  tlie  Diseases  of  the 
Bladder  and  Urethra  in  the  Female,  as  well  as  by  other  au- 
thors of  equal  or  less  prominence,  who  have  attended  to  the 
same  subject. 

"A  lady  thirty-seven  years  of  age,  whose  health  has  been 
uninterruptedly  good — the  mother  of  six  children,  the  last 
being  an  infant  of  four  months — applied  to  me  for  treat- 
ment for  (what  she  considered  the  ailment  to  be)  inconti- 
nence of  urine.  She  stated  that  the  condition  had  come  on 
gradually,  at  the  first  amounting  to  a  mere  frequency  of  uri- 
nation during  the  day,  without  any  attendant  pain  or  other 
symptom  which  attracted  her  attention.  This  frequency  had 
increased,  however,  to  such  an  extent  as  to  seriously  embar- 
rass her  in  the  performance  of  domestic  duties,  and  prevent 
her  from  visiting  her  friends.  Moreover,  she  soon  became 
troubled  at  night,  often  rising  six  or  perhaps  a  dozen  times  in 
obedience  to  the  urgent  calls  for  urination.  The  amount  of 
urine  passed  at  each  discharge  was  not  large,  but  exceeded  in 
quantity  that  ordinarily  retained  in  cases  of  acute  cystitis, 
which  the  affection  in  many  respects  resembled. 

"There  was  no  deposit  worth  noting  in  the  urine,  and  the 
secretion  appeared  to  be  somewhat  higher  colored  than  nor- 
mal. There  was,  also,  a  superabundance  of  mucus  in  the 
form  of  flocculi,  but  no  pus  or  blood. 

"As  the  case  progressed,  the  desire  to  urinate  was  pre- 
ceded by  a  sharp  twinge  of  pain  which,  the  patient  said, 
'was  low  down,  at  the  very  neck  of  the  bladder,'  but  which 
was  immediately  relieved  on  emptying  the  viscus.  There  was 
no  tenderness  at  any  point,  except  a  slight  pain  experienced 
when  the  neck  of  the  bladder  was  firmly  pressed  upon.  The 
frequency  of  micturition  increased  to  almost  constant  drib- 
bling from  the  bladder ;  both  daily  and  nightly  the  cloud 
of  mucus  in  the  bladder  was  much  augmented,  and  while 
the  color  appeared  to  remain  unchanged,  there  was  evidently 
a  large  excretion  of  solid  matter  composed  probably  of  phos- 
phates. 

"The  tripod  of  treatment — namely,  rest,  opium,  and  alka- 


FUNCTIONAL   DISEASES  OP  THE  BLADDER.  421 

lies — upon  wMch.  Van  Buren  and  Keyes  conjointly  protest  the 
successful  management  of  cystitis  rests,  was  relied  on  to  re- 
lieve what  I  now  feared  was  a  case  of  this  distressing  disease, 
the  cause  of  which  I  could  not  then  determine.  The  consti- 
tutional effect  of  belladonna  was  evoked  also,  to  mitigate  the 
symptoms  ;  and,  finally,  hot-water  vaginal  injections  were 
employed  for  their  well-known  analgesic  and  antiphlogistic 
effects  upon  the  pelvic  viscera. 

"At  thQ  beginning  of  the  third  week  from  the  first  appear- 
ance of  the  symptoms  the  patient  complained  of  slight  chilli- 
ness toward  evening,  and  it  was  observed  that  this  was  fol- 
lowed by  fever,  the  thermometer  in  the  mouth  registering 
101°.  These  symptoms  were  interpreted  to  indicate  the  con- 
stitutional expression  of  the  local  inflammation  existing  in 
the  bladder.  Hence  no  special  attention  was  directed  toward 
them.  The  chilliness  was  repeated,  however,  on  the  third 
evening,  and  on  the  fourth  day  at  the  same  hour  reappeared 
as  the  prodrome  of  a  marked  rigor,  followed  by  an  abrupt 
rise  of  temperature  to  103°,  succeeded  by  sweating  and  a  re- 
turn to  the  normal  temperature  in  about  four  hours,  thus 
clearly  demonstrating  a  well-defined  periodicity  of  the  febrile 
movement. 

"Suspicion  being  now  aroused  as  to  the  essential  nature  of 
the  case,  the  patient  was  promptly  placed  on  ten-grain  doses 
of  the  sulphate  of  quinine  to  be  taken  every  four  hours  with 
mercurial  and  saline  purgatives,  the  latter  being  indicated  by 
the  appearance  of  the  tongue  and  the  confined  state  of  the 
bowels,  which  was  due  not  altogether  to  the  opium  adminis- 
tered, since  this  physical  modifier  had  been  exhibited  both 
freely  and  simultaneously. 

"At  the  end  of  four  days  from  the  administration  of  the 
first  dose  of  quinine  the  patient  was  virtually  convalescent. 
During  this  period  no  opiate  was  employed  nor  any  other 
medicine  but  quinine  taken,  save  an  occasional  dose  of  neu- 
tral mixture,  chiefly  for  its  sudorific  effect.  Nevertheless,  the 
irritation  of  the  bladder  did  not  return,  and  the  close  of  the 
week  found  the  patient,  although  debilitated  by  the  trying 


422  MEDICAL  GYNECOLOGY. 

ordeal  through  which  she  had  passed,  enabled  to  resume  her 
accustomed  duties." 

Periodical  Attacks  of  Freq[uent  and  Painful  Urination  and  Vesical 
Tenesmus  caused  by  Malaria. — My  hospital  clinical  records  con- 
tain this  case  in  poiut :  In  the  afternoon  of  each  day  the  pa- 
tient experienced  a  sense  of  heat  and  burning  in  the  bladder 
and  urethra,  with  a  frequent  and  irresistible  desire  to  urinate. 
Evacuation  of  the  bladder,  attended  with  a  great  deal  of 
smarting  and  pain  in  the  urethra,  did  not  give  complete  re- 
lief, but  left  some  vesical  tenesmus  which  increased  in  sever- 
ity as  the  bladder  became  distended.  These  symptoms  per- 
sisted during  the  night  and  kept  her  awake  ;  but  toward 
morning  her  sufferings  entirely  left  her,  and  she  became  quite 
comfortable  until  the  next  afternoon.  This  condition  had 
existed  for  nearly  two  months,  and  accordingly  her  digestion 
had  become  impaired  and  her  strength  diminished.  This  was 
attributed  by  her  to  the  want  of  sleep,  and  no  doubt  was  due 
in  part  to  this  cause.  The  urine  was  examined  and  found  to 
be  normal  except  that  it  contained  a  slight  excess  of  phos- 
phates. She  was  carefully  examined,  and  no  evidence  of 
organic  disease  was  found. 

While  she  always  enjoyed  full  health  and  had  been  a 
vigorous  woman,  she  had  had  an  attack  of  malarial  fever 
about  six  months  before  I  saw  her,  and  at  the  time  this  blad- 
der trouble  came  on  she  said  she  had  symptoms  of  her  former 
ague.  From  the  facts  in  her  history  I  ventured  to  state  to 
my  class  that  this  was  a  functional  derangement  of  the  blad- 
der and  urethra  caused  by  malaria,  which  w^ould  promptly 
yield  to  Judicious  doses  of  quinine.  I  accordingly  prescribed 
twenty  grains  of  quinine  to  be  taken  between  early  morn- 
ing and  noon,  to  be  followed  by  two-grain  doses  before 
meals,  with  four  drops  of  Fowler's  solution  of  arsenic  after 
meals.  She  was  ordered  to  report  at  the  clinic  the  fol- 
lowing week.  She  did  so,  and  declared  that  she  had  been 
perfectly  well  since  the  first  day  she  took  the  medicine. 
The  quinine  and  arsenic,  in  small  doses,  were  continued  for 
three  weeks,  at  the  end  of  which  time  she  reported  herself 


FUNCTIONAL  DISEASES  OP  THE  BLADDER.  423 

as  having  been  well  and  free  from  all  irritation  of  the  uri- 
nary organs. 

!N"o  change  in  the  character  of  the  urine  could  have  oc- 
curred to  produce  such  marked  periodicity  in  the  functional 
derangement  of  the  bladder  and  urethra ;  moreover,  the 
urine  was  found  to  be  normal,  and  she  completely  recovered 
on  the  use  of  quinine. 


CHAPTER  XXXiy. 

FUlS'CTIOlSrAL   DEEAISTGEMEISTTS   OF   THE   UEUSTAET   ORGANS 
CAUSED   BY   DISEASES    OF   OTHER   PELYIC    ORGAJSTS. 

FuisrcTioisrAL  diseases  of  the  bladder  caused  by  disorders 
of  the  neighboring  jDelvic  organs  are  frequently  met  with  in 
practice.  In  this  class  the  vesical  trouble  is  secondary  to 
some  primary  and  more  important  affection,  but  the  derange- 
ment of  its  function  is  often  the  most  prominent  and 
troublesome  symptom  ;  hence  it  is  important  to  understand 
its  relation  to  the  primary  disease,  in  order  to  make  a  cor- 
rect diagnosis  and  to  treat  such  cases  properly. 

This  class  of  functional  disorders  frequently  resembles 
in  history  some  of  the  organic  diseases  of  the  bladder,  so 
that  care  is  necessary  to  distinguish  the  one  from  the  other. 
What  I  say  upon  the  subject  will  have  reference  only  to 
diagnosis.  When  we  know  that  the  bladder  trouble  is  due 
to  disease  of  some  other  organ,  attention  is  at  once  turned 
to  the  primary  malady.  These  facts  must  be  borne  in  mind, 
and  symptoms  must  not  be  mistaken  for  disease. 

Diseases  of  the  rectum  affect  the  bladder  sympathetically, 
and  irritation  and  pain  in  the  rectum  from  any  cause  affect 
it  more  or  less.  Chronic  hsemorrhoids  will  cause  frequent 
urination,  and  so  will  rectal  fissure,  especially  after  defeca- 
tion. Abscesses  in  the  neighborhood  of  the  rectum  will  fre- 
quently cause  retention  of  urine. 

One  very  interesting  case  of  this  kind  occurred  in  the 
practice  of  my  friend  Dr.  Gushing.  The  patient  had  an 
abscess  in  the  neighborhood  of  the  rectum  which  caused  re- 
tention of  the   urine,  and  this  in  turn  caused  acute  renal 

424 


FUNCTIONAL   DERANGEMENTS  OP  THE   URINARY  ORGANS.  425 

disease.  After  the  bladder  liad  been  emptied  and  kept  from 
overdistention  for  some  time,  the  urine  was  examined  and 
found  to  contain  albumin  and  casts.  She  made  a  rapid 
recovery,  and  all  evidence  of  kidney  disease  soon  disap- 
peared. 

Very  troublesome  vesical  irritation  may  come  from  as- 
carides.  The  itching  of  the  anus  and  rectum  caused  by 
these  troublesome  little  worms  keeps  up  an  almost  constant 
desire  to  ujinate.  Children  are  most  troubled  with  these 
parasites,  but  women  often  suffer  in  the  same  w^ay. 

Marion  Sims  points  out  the  interesting  fact  that  almost  all 
cases  of  vaginismus  are  accompanied  by  an  irritable  condi- 
tion of  the  bladder,  and  that,  as  the  terminal  fibers  of  the  hy- 
men often  extend  from  the  meatus  to  the  vesical  neck,  cysto- 
spasm  may  in  these  cases  be  due  to  reflex  nerve  irritation. 
An  attempt  to  catheterize  these  patients  is  as  liable  to  cause 
spasm  of  the  bladder  as  an  analogous  attempt  to  examine 
the  uterus  would  be  in  producing  vaginismus.  In  these 
cases  the  hymen  should  be  excised,  and  the  vaginismus 
treated  after  the  usual  methods. 

'  Acute  pelVic  peritonitis  and  cellulitis  cause  great  distress 
in  many  cases  by  their  effect  on  the  bladder.  A  constant  de- 
sire to  urinate  without  the  ability  to  make  sufficient  strain- 
ing effort  to  accomplish  the  object  is  very  often  observed  in 
all  these  acute  pelvic  inflammations.  The  disturbance  of  the 
bladder  is,  of  course,  only  a  symptom  of  the  primary  and 
more  important  trouble,  and  simply  requires  to  be  mentioned 
here.  The  after-effects  of  pelvic  peritonitis  are  what  I  at 
present  especially  desire  to  call  attention  to. 

The  adhesions  formed  by  the  products  of  the  inflamma- 
tion of  the  pelvic  peritonaeum  are  in  some  cases  sufficient  to 
prevent  the  normal  filling  of  the  bladder,  and  frequent 
urination  then  becomes  a  necessity.  This  derangement  of 
function  generally  exists  alone.  The  urine  is  retained  with- 
out trouble  up  to  a  certain  amount;  it  is  passed  without 
pain,  and  no  vesical  tenesmus  follows  evacuation.  Unless  the 
contraction  of  the  bladder  is  great,  and  the  frequent  neces- 


426  MEDICAL  GYNECOLOGY. 

sity  to  urinate  v^ry  troublesome,   patients  rarely  consult  a 
physician  for  it. 

Paralysis  of  the  bladder  with  retention  may  be  caused  by 
a  peculiar  condition  of  oedema,  by  which  the  detrusors  are 
rendered  powerless  to  act.  It  is  usually  caused  by  disease 
of  the  cervix  uteri,  parametritis,  or  peritonitis. 

IV.    DERANGEMENTS   DUE   TO   OVARIAN    AFrECTIONS. 

In  disease  of  the  ovaries  we  sometimes  find  that  the  blad- 
der suffers  very  much  from  deranged  nerve  action.  The 
clearest  and  best  account  of  this  form  of  functional  bladder 
trouble  is  given  by  Fothergill  in  his  paper  on  Ovarian  Dys- 
pepsia, published  in  the  American  Journal  of  Obstetrics, 
January,  1878.  In  speaking  of  the  derangement  of  the  stom- 
ach and  pelvic  organs  he  says  : 

"It  soon  became  clear  that  there  was  some  condition  ex- 
isting which  stood  in  a  causative  relation  to  both  the  dyspep- 
sia and  the  uterine  disturbance.  That  condition  was  quickly 
seen  to  be  a  state  of  vascular  excitement  in  one  or  both  ova- 
ries, usually  the  left  ovary.  This  condition  Barnes  terras 
'ophoria.'  In  this  state  there  is  always  more  or  less  pain 
constantly  in  the  iliac  fossa,  more  rarely  on  the  right,  much 
aggravated  at  the  catamenial  periods,  when  the  pain  shoots 
from  the  turgid  ovary  down  the  thigh  of  the  corresponding 
side  along  the  genito-crural  nerve.  This  painful  state  is  other- 
wise known  as  'ovarian  dysmenorrhoea.'  When  pressure  is 
made  over  this  tender  ovary  during  the  catamenial  flow,  acute 
pain  is  experienced.  Pressure  also  elicits  pain  during  the 
intermenstrual  interval. 

"At  the  same  time  that  acute  pain  is  felt,  evidence  is  fur- 
nished of  emotional  perturbation  ;  the  patient  feels  as  if  about 
to  faint,  or  'feels  queer  all  over,'  as  some  express  it,  and  the 
changes  in  the  patient's  countenance  speak  of  something 
more  than  ordinary  pain.  It  is  evident  that  there  is  a  wave 
of  nerve  perturbation  set  up,  which  excites  more  than  the 
sensation  of  pain.  Commonly  the  patient  feels  sick  and  faint 
after  the  momentary  pressure,  and  asks  to  be  permitted  to  sit 


FUNCTIONAL  DERANGEMENTS   OF  THE   URINARY  ORGANS.  427 

down.  If  a  careful  physical  examination  be  made,  it  will  be 
found  that  there  is  an  enlarged  and  tender  ovary,  which  may 
sometimes  be  caught  between  the  finger  in  the  vagina  and  the 
fingers  of  the  other  hand  applied  to  the  abdominal  wall  of 
the  ovary.  Such  manipulation  elicits  manifestations  of  acute 
suffering  from  the  patient.  Frequently  the  rectus  muscle 
over  the  tender  ovary  is  hard  and  rigid,  so  as  to  place  the 
organ  as  perfectly  at  rest  as  is  possible ;  just  as  we  see  the 
rectus  stiffen  and  become  rigid  over  the  liver  when  there  is  a 
hepatic  abscess,  and  thus  to  secure  rest,  as  regards  movement, 
for  that  viscus.  ... 

"Not  rarely,  too,  there  is  set  up  a  very  distressing  con- 
dition— viz.,  that  of  recurring  orgasm.  This  occurs  most 
commonly  during  sleep — '  the  period  par  excellence  of  reflex 
excitability.'  In  more  aggravated  cases  it  also  occurs  during 
the  waking  moments,  and  this  it  does  without  any  reference 
to  psychical  conditions. 

"  The  centers  of  the  pelvic  viscera  lie  near  together  in  the 
cord,  and  the  condition  of  one  is  readily  communicated  to 
another.  The  brief  recurrent  orgasm  affects  the  bladder  cen- 
ters, the  call  to  make  water  is  sudden  and  imperative,  and 
must  be  attended  to  at  once,  or  a  certain  penalty  be  paid  for 
non-attention.  This  last  is  not  a  common  condition,  fortu- 
nately, but  it  is  a  source  of  great  suffering,  bodily  and  mental, 
when  it  does  occur.  The  condition  of  the  ovary  also  acts  re- 
flexly  upon  the  uterus,  and  keeps  it  in  a  state  of  persistent 
erection  and  high  vascularity,  with  the  normal  phenomena 
attendant  thereupon." 

It  is  evident  that  this  form  of  bladder  trouble  can  only  be 
relieved  by  treatment  of  the  ovarian  disease,  for  which  bro- 
mide of  potassium  and  counter-irritation  are  very  serviceable, 
with,  of  course,  attention  to  the  general  health. 

Symptomatology. — In  all  of  these  nervous  affections  of  the 
urinary  organs  pain  and  a  feeling  of  weight  and  uneasiness 
in  the  region  of  the  bladder  are  usually  present.  Still,  the 
most  constant  and  distressing  symptom  is  the  frequent  and 
painful  desire  to  micturate,  which  the  patient  tries  often  to 

28 


428  MEDICAL  GYNECOLOGY. 

relieve,  a  few  drops  only  being  passed  at  a  time.  Of  course, 
there  are  varying  grades  of  this  malady,  in  some  of  which 
these  symptoms  are  by  no  means  so  troublesome.  In  extreme 
cases,  occasionally,  when  a  little  urine  collects  in  the  bladder, 
the  pain  and  irritability  are'  so  intense  that  it  is  spurted  out 
by  a  very  forcible  and  painful  contraction  of  the  organ.  The 
sense  of  weight  and  bearing  down  are  most  intense  in  the 
upright  position.  The  pains  may  be  confined  to  the  neck  or 
base  of  the  bladder,  or  they  may  shoot  in  all  directions.  The 
suffering  in  micturition  may  be  present  at  the  beginning,  but 
is  usually  most  severe  during  and  after  the  completion  of 
the  act. 

The  local  pain  and  distress,  with  the  frequent  urination 
and  unrest,  react  upon  the  general  nervous  system,  thereby 
greatly  aggravating  the  original  disorder.  This  lowered  sys- 
temic condition  in  turn  affects  the  local  trouble,  and  so  the 
one  is  continually  aggravating  the  other.  In  this  way  the 
patient,  if  not  relieved,  goes  on  from  bad  to  worse,  until  the 
host  of  phenomena  characteristic  of  nervous  prostration  and 
general  ill  health  are  developed. 

In  certain  cases  the  sufferers  are  by  no  means  so  badly 
situated,  but,  sooner  or  later,  time  and  neglect  tend  to  pro- 
duce these  results.  In  some  instances,  again,  the  suffering 
gradually  disappears,  and  the  patient  is  restored  to  health 
without  much  aid  from  treatment.  The  abnormal  condition 
appears  to  wear  itself  out. 

Diagnosis. — The  symptoms  I  have  given  are  by  no  means 
pathognomonic  of  these  affections,  the  same  being  produced 
by  organic  disease  of  the  bladder,  by  calculi,  and  various 
other  causes.  The  diagnosis  must  be  made  by  exclusion. 
The  first  thing  to  do  is  to  make  a  careful  microscopical  and 
chemical  analysis  of  the  urine.  Not  only  can  local  organic 
trouble  thus  be  discovered,  but  important  knowledge  as  to 
the  state  of  the  general  system  obtained. 

If  no  urinary  abnormity  is  found,  a  careful  external  and 
internal  examination  of  the  organ  itself  should  be  made.  A 
finger  should  first  be  passed  into  the  vagina,  and  an  endeavor 


FUNCTIONAL  DERANGEMENTS  OF  THE  URINARY  ORGANS.  4-29 

made  to  ascertain,  by  pressure  on  the  vesico- vaginal  septum, 
whether  there  is  any  abnormal  sensitiveness  of  the  vesical 
base  or  neck,  or  both.  Then  the  sensibility  of  the  mucous 
membrane  should  be  tested  by  the  introduction  of  a  sound. 
If  sufficient  cause  be  not  found  in  either  the  urine  or  the 
bladder,  the  case  may  be  set  down  as  one  of  pure  neurosis,  to 
be  treated  as  I  shall  hereafter  describe.  Systemic  conditions, 
such  as  hysteria  or  chlorosis,  should  be  considered,  as  they 
point  to  a  tendency  to  neurotic  difficulties,  liable  to  be  local- 
ized. 

Prognosis. — As  a  rule,  the  prognosis  is  favorable ;  but 
this,  however,  is  not  always  so.  The  longer  the  affection  has 
lasted,  the  more  difficult  it  is  to  cure.  Most  cases  may  be 
cured  in  a  few  weeks'  time,  and  even  the  most  obstinate  in  a 
few  months.  The  danger  to  the  patient  lies  in  the  fact  that 
continuance  of  the  disorder  is  liable  to  bring  on  an  organic 
lesion,  and,  whether  this  results  or  not,  the  reaction  on  the 
general  system  tends,  in  the  worst  cases,  to  produce  hypo- 
chondriasis or  even  melancholia. 

Causation. — These  nervous  affections  of  the  bladder  occur 
most  frequently  in  those  of  the  nervous  temperament.  A 
highly  developed  nervous  system  predisposes  one  to  nervous 
affections  of  all  kinds.  Especially  is  this  the  case  if  the  sub- 
ject is  not  well  sustained  by  a  vigorous  nutritive  system. 
Those  in  whom  the  emotional  elements  predominate  are  more 
liable  to  nervous  troubles  of  the  bladder  than  those  of  a 
more  intellectual  type.  Those  with  the  neuropathic  tendency 
or  with  the  psychic  diathesis  are  included  in  this  class. 

The  exciting  causes  include  all  influences  which  depress 
or  exhaust  the  nervous  system.  Mental  action  or  excitement 
which  tends  to  increase  the  excitability  of  the  nervous  system 
may  derange  the  function  of  the  bladder.  Constitutional 
diseases  which  lower  the  tone  of  the  whole  organization  also 
tend  to  produce  the  ailments  now  under  discussion. 

It  is  not  possible  to  give  any  satisfactory  explanation  of 
the  reason  why  the  innervation  of  the  bladder  becomes  de- 
ranged in  some  persons  from  causes  which  are  in  others  in- 


430  MEDICAL  GYNECOLOGY. 

operative.  It  may  be  that  those  who  are  most  susceptible  to 
these  causes  are  so  because  of  some  inherited  sensitiveness  of 
the  pelvic  organs  which  responds  to  the  disturbing  influences. 
This  appears  to  be  the  case  with  those  who  suffer  from  irrita- 
tion of  the  bladder  resulting  from  ovarian  disease.  This  is 
apparent  from  the  fact  that  one  affected  with  disease  of  the 
ovaries  will  suffer  from  derangement  of  the  function  of  the 
stomach,  while  another  having  a  similar  ovarian  affection  will 
suffer  most  from  frequent  urination. 

Regarding  the  causative  relations  of  malaria  to  irritation 
of  the  bladder,  all  that  can  be  said  at  the  present  time  is  that 
this  materies  morM  appears  to  act  upon  that  viscus  through 
the  nervous  system. 

Treatment. — This  may  be  classed  as  general  and  local. 
In  pure  neuroses,  attention  should  first  be  directed  to  improv- 
ing the  hygienic  condition  of  the  patient.  Cheerful  company 
should  be  provided  at  meals  and  at  other  times,  and  there 
should  be  exercise  suited  to  the  strength  of  the  patient,  daily 
ablution,  and  proper  regulation  of  diet.  This  latter  should 
be  simple  and  nourishing,  and  of  a  kind  calculated  to  pro- 
duce as  little  urea  and  urinary  solids  as  possible.  In  cases 
where  the  urine  is  limpid,  the  opposite  course  is  to  be  pur- 
sued. Pastry,  Irritating  condiments,  and  stimulants,  except 
in  rare  cases,  should  be  prohibited.  The  exception  to  this  is 
where  a  state  of  the  system  calling  for  stimulation  exists.  In 
such  instances  the  irritation  of  the  bladder  produced  by  their 
use  may  be  more  than  counterbalanced  by  the  good  they  do 
the  system  generally.  Tea  is  better  than  coffee,  but  neither 
is  to  be  used  in  any  great  quantity. 

The  condition  of  the  urinary  secretion  must  be  carefully 
watched,  and  anything  abnormal  quickly  and  judiciously  cor- 
rected. Where  there  is  any  tendency  to  excessive  acidity 
the  effervescing  waters,  rich  in  carbonic-acid  gas,  will  be 
found  of  use.  The  bowels  should  be  kept  moderately  well 
open,  but  should  never  be  irritated  with  active  cathartic 
agents. 

Tonics  and  medicinal  stimulants  are  often  of  great  value 


FUNCTIONAL   DERANGEMENTS   OP   THE   URINARY  ORGANS.  431 

when  judiciously  prescribed.  Strychnine  in  very  small  doses 
does  not,  as  might  be  supposed,  aggravate  the  irritable  con- 
dition of  these  organs.  The  nerve-tone  being  below  par,  this 
remedy,  by  gradually  increasing  it,  is  of  great  service,  but  in 
large  doses  it  is  undoubtedly  hurtful,  and  should  never  be 
long  continued.  Quinine,  iron,  and  the  various  simple  and 
compound  vegetable  bitters  act  well  in  the  cases  where  their 
use  is  indicated.  If  the  irritation  is  extreme,  various  sooth- 
ing emulsiojis  and  decoctions  may  be  given  by  the  mouth. 
Of  these,  preparations  of  marsh  mallow,  triticum  repens,  aca- 
cia, pareira  brava,  and  bucliu  act  well.  Emulsio  amygdalae  is 
much  used  and  highly  recommended  by  the  German  authors. 

Some  objections  have  been  raised  to  the  use  of  these  drugs 
on  the  score  that  they  increase  the  flow  of  urine,  thus  aggra- 
vating the  local  irritability.  The  fact  is,  however,  that  the 
presence  of  fairly  normal  urine  in  moderate  quantity  in  the 
bladder  seems  to  relieve  rather  than  increase  its  irritable  con- 
dition. 

The  local  treatment  may  be  as  follows  :  A  cupful  of  warm 
hop-tea  containing  from  twenty  to  forty  drops  of  laudanum 
may  be  injected  into  the  rectum.  Suppositories  containing 
atropine  or  hyoscyamus  act  as  well,  if  not  better.  Emul- 
sions, decoctions,  and  infusions  of  cannabis  Indica,  hyoscy- 
amus, belladonna,  and  other  drugs  of  this  class  may  be  ad- 
ministered by  the  mouth,  as  the  case  may  require.  Good 
effects  have  followed  the  use  of  rectal  injections  containing 
chloral  hydrate  (grains  xv  to  water  ^  j  or  §  ij).  It  may  also 
be  given  by  the  mouth,  but  does  not  usually  act  so  quickly 
or  have  such  a  direct  local  effect.  The  injection  into  the 
bladder  of  a  solution  containing  morphine,  followed  by  cau- 
terization of  the  mucous  membrane,  is  highly  spoken  of  by 
Braxton  Hicks.  In  this  way  he  claims  to  deaden  the  reflex 
irritability  of  the  membrane, 

I  must  insist  on  this  :  that  opium  be  used  in  such  cases 
with  great  care,  and  never  long  continued.  If  this  rule  is 
neglected,  it  will  lead  many  nervous  patients  to  contract  the 
opium  habit,  a  disease  which  is  worse  than  irritable  bladder. 


432  MEDICAL  GYNECOLOGY. 

Debont  recommends  the  use  of  bromide  of  potassium  by 
tlie  mouth,  and  also  in  suppository,  combining  with  it  in  the 
latter  tincture  of  opium  and  belladonna.  I  prefer  hydrobro- 
mic  acid  to  the  bromide  of  potassium.     I  omit  the  opium. 

When  the  trouble  is  due  to  masturbation,  moral  and  men- 
tal influences  must  be  brought  to  bear,  as  well  as  medication 
and  regulation  of  diet  and  habits.  In  these  cases  the  bro- 
mides will  be  of  service. 

When  complicated  with  malaria,  the  treatment  is  usually 
simple  and  satisfactory.  Quinine  in  full  doses  for  one  day, 
and  then  in  small  doses  before  meals  for  a  week,  will  usually 
cut  short  the  trouble  and  prevent  its  return.  The  digestive 
organs  require  attention  when  they  are  out  of  order,  as  they 
usually  are. 

Wlien  this  affection  occurs  in  connection  with  hysteria 
the  original  disease  should  be  treated,  not,  however,  neglect- 
ing the  local  trouble.  When  accompanying  acute  or  chronic 
systemic  diseases,  it  is  only  relieved  when  the  primary  ail- 
ment is  cured,  although  the  distress  in  the  meantime  may  be 
greatly  alleviated  by  the  treatment  already  recommended. 

Vesical  Tenesmus  and  Frequent  Urination  due  to  Prolapsus  and 
Inflammation  of  the  Ovaries. — With  prolapsus  of  the  ovaries,  and 
inflammatory  affections  of  these  organs,  irritation  of  the 
bladder  often  occurs.  This  is  illustrated  by  the  following 
case  : 

A  young  girl  of  twenty-one,  who  was  brought  to  me,  com- 
plained of  great  pain  in  the  pelvis,  which  was  much  aggra- 
vated by  standing  or  walking.  Her  suffering  Avas  constant, 
but  was  tolerable  when  she  remained  in  the  recumbent  posi- 
tion. She  began  to  complain  about  six  months  before  I  saw 
her,  and  about  the  same  time  found  that  she  was  obliged  to 
urinate  too  often,  and  that  there  was  an  uneasy  feeling  in  the 
bladder  most  of  the  time — afeeling  as  if  it  had  not  been  fully 
evacuated. 

She  was  much  worse  at  her  menstrual  periods.  Upon  a 
thorough  examination  I  found  both  ovaries  prolapsed,  slight- 
ly enlarged,  and  exceedingly  tender,  though  in  every  other 


FUNCTIONAL  DERANGEMENTS  OP  THE   URINARY  ORGANS.  433 

respect  she  was  perfectly  well.  In  consultation  with  her 
physician,  a  course  of  treatment  for  the  ovarian  disease  was 
decided  upon.  This  was  fully  and  faithfully  tried  for  over  a 
year,  but  at  the  end  of  that  time  she  was  worse.  She  was 
then  quite  impatient,  being  very  nervous  and  irritable  from 
her  confinement  and  suffering  due  to  the  bladder  irritation. 
She  could  not  urinate  without  getting  up,  and  the  erect  posi- 
tion increased  the  ovarian  pain.  The  ovaries  were  still  pro- 
lapsed, and  Just  as  tender — in  fact,  more  so  than  they  had 
been. 

The  complete  failure  of  treatment  up  to  this  time  indicated 
that  removal  of  the  ovaries  was  the  only  thing  that  promised 
to  give  her  relief.  Accordingly,  the  ovaries  were  removed, 
she  made  a  rapid  recovery  from  the  operation,  and  was  com- 
pletely relieved  not  only  from  her  ovarian  pain  but  also  from 
the  frequent  urination  and  vesical  tenesmus.  It  should  be 
stated  that  at  no  time  was  there  any  evidence  of  cystitis  found 
upon  frequent  and  careful  examinations. 


CHAPTEE  XXXy. 

OEGAlSriC   DISEASES    OF   THE   BLADDER. 

HAViisra  treated  of  the  functional  diseases  of  the  bladder, 
I  come  now  to  the  organic  which  naturally  fall  under  the  care 
of  the  physician.  Under  this  head  I  shall  discuss  infiamma- 
tory  affections. 

Well-defined  typical  inflammation  presents  during  its 
course  certain  peculiarities  which  are  characteristic  of  it, 
and  without  the  existence  of  which  the  disorder  can  not  be 
called  true  inflammation.  Inflammation,  however,  varies  in 
character  with  the  tissue  or  organ  involved,  and  the  extent 
or  intensity  of  the  disease ;  and,  while  there  is  really  but 
one  process  of  inflammation,  its  products  must  necessarily 
vary  greatly,  as  that  process  is  often  interrupted,  prolonged, 
or  modifled  in  various  ways.  Its  divers  grades  or  forms  are 
distinguished  as  acute,  chronic,  catarrhal,  interstitial,  sup- 
purative, croupous,  diphtheritic,  and  gonorrhoeal.  The  rare 
forms,  and  those  requiring  surgical  care,  will  be  omitted. 

Before  entering  upon  the  consideration  of  cystitis  in  its 
many  forms  I  shall  speak  of  hypersemia  and  haemorrhage  of 
the  bladder.  This  latter  affection  might  more  properly,  per- 
haps, be  considered  under  another  head,  but  it  is  so  closely 
connected  vdth  hypersemia  and  inflammation  that  I  prefer  to 
treat  it  here. 

Hypersemia. — The  hypersemia  of  the  mucous  membrane  is 
the  first  morbid  change  observed,  and  with  it  disorders  of  in- 
nervation, as  is  evidenced  by  derangement  of  function  and 
sensation.  In  many  cases,  however,  the  vascular  engorge- 
ment involves  the  whole  organ. 

434 


ORGANIC   DISEASES  OF  THE   BLADDER.  435 

In  hypersemia  of  the  mucous  membrane  of  the  bladder  the 
blood-vessels  are  distended,  and  becoming  prominent  and 
apparently  more  numerous,  give  to  it  a  bright-red  color.  The 
arterioles  are  the  first  to  be  affected.  If  the  hypersemia  is 
not  marked,  or  is  produced  by  some  transient  cause  and  not 
aggravated,  it  may  pass  off  in  a  short  time,  and  leave  the  mem- 
brane in  its  normal  condition.  If  it  is  of  a  severe  type,  how- 
ever, rupture  of  some  of  the  vessels  may  occur,  the  haemor- 
rhage taking  place  either  on  the  free  surface  of  the  mem- 
brane or  beneath  its  epithelial  layer.  Should  this  condition 
continue,  the  hypersemia  which  began  in  the  arteries  extends 
to  the  venous  side  of  the  circulation,  and  the  vessels  become 
more  prominently  and  uniformly  distended.  The  congestion 
may  also  begin  on  the  venous  and  extend  to  the  arterial  side, 
as  in  sudden  interference  with  portal  circulation.  As  a  rule, 
however,  it  begins  in  the  arteries.  These  facts  have  been  dis- 
covered by  the  use  of  the  cystoscope. 

A  clear  distinction  must  be  made  between  the  acute  con- 
gestion of  which  I  am  now  speaking  (and  which  is  chiefly  con- 
fined to  the  smaller  vessels)  and  passive  hypersemia  with  a 
varicose  or  hsemorrhoidal  condition  of  the  veins  about  the 
neck  of  the  bladder.  This  hsemorrhoidal  condition  I  shall 
speak  of  later. 

Symptomatology. — The  symptoms  of  acute  hypersemia  of 
the  bladder,  as  a  rule,  occur  suddenly,  frequent  but  painless 
urination  being  the  principal  one.  There  is  often  a  sense  of 
heat  and  heaviness  in  the  region  of  the  bladder,  which  is 
greatly  aggravated  by  standing  or  walking.  This  symptom 
is  more  pronounced  when  the  entire  organ  is  congested  and 
the  large  vessels  beneath  the  mucous  membrane  are  affected. 
When  the  urethra  is  involved,  the  patient  complains  that  the 
urine  "  scalds  "  her. 

The  general  system  is  not  disturbed — i.  e.,  the  pulse  and 
temperature  remain  normal,  or  nearly  so,  unless  the  conges- 
tion is  caused  by  malaria,  which  is  often  the  case.  The  phys- 
ical signs  are  mostly  negative.  The  composition  of  the  urine 
is  unchanged,  save  for  a  possible  excess  of  mucus,  and  a  few 


436  :\IED1CAL   GYXECOLOGY, 

blood-globules  present.  There  may  be  some  tenderness  on 
pressure  over  the  bladder.  The  endoscope  (when  there  is 
an  opportunity  to  use  it,  which  is  very  rare  in  this  trouble) 
shows  an  increased  redness  of  the  mucous  membrane,  with 
occasionally  an  excess  of  mucus  on  its  surface. 

Diagnosis. — The  diagnosis  has  to  be  made  by  exclusion, 
the  natural  history  of  the  affection  having  in  it  nothing  pathog- 
nomonic. It  is  liable  to  be  confounded  with  sympathetic  or 
other  functional  derangement  of  the  bladder,  caused  by  sud- 
den dislocations  of  the  uterus  or  by  pelvic  inflammation,  such 
as  pelvic  peritonitis  and  its  results.  The  former  can  be  ex- 
cluded by  an  examination  of  the  pelvic  organs,  and  the  latter 
by  the  constitutional  symptoms  of  inflammation  and  the  signs 
of  such  pelvic  disease. 

Causes. — The  causes  of  hyperfemia  of  the  bladder  are  ex- 
posure to  cold  (especially  during  the  menstrual  period),  wet- 
ting the  feet,  overexertion  in  walking  or  using  the  sewing 
machine,  excessive  venereal  indulgence,  constipation  of  the 
bowels  from  torpor  of  the  portal  circulation,  the  too  free  use 
of  stimulants,  and  the  eating  of  improper  articles  of  food. 

Treatment.— ThQ  treatment  should  be  directed  to  equaliz- 
ing the  circulation,  diaphoretics,  warm,  stimulating  foot- 
baths, hot  applications  over  the  epigastrium,  and,  above  all, 
rest  in  the  recumbent  position,  or,  better  still,  with  the  pelvis 
elevated.  If  the  bowels  are  confined,  they  should  be  emptied 
by  saline  laxatives.  "When  there  is  much  irritation  of  the 
bladder,  causing  frequent  urination  and  vesical  tenesmus,  co- 
nium  with  camphor  should  be  given,  or  suppositories  of  bel- 
ladonna and  stramonium  introduced  into  the  vagina.  The 
vaginal  douche  of  hot  water  gives  relief  in  some  cases  and 
should  be  tried.  Under  this  treatment  the  trouble  will  usu- 
ally pass  off  in  a  short  time.  It  may,  however,  go  on  to  the 
development  of  cystitis.  In  the  majority  of  cases  there  is 
some  disease  or  derangement  of  the  nutritive  system  and  a 
consequent  abnormal  state  of  the  urine.  This  condition  should 
be  corrected  by  appropriate  medication. 

Hsemorrhage  from  the  Bladder,  or  (if  I  may  be  allowed  to 


OUaANIC   DISEASES  OP  THE   BLADDER.  437 

coin  a  word)  "cystorrhagia,"  is  usually  due  to  some  impor- 
tant disease  of  that  organ,  and  is  therefore  rather  a  symptom 
than  a  disease.  For  this  reason  I  shall  at  present  confine  my 
remarks  to  hsemorrhage  when  caused  by  acute  congestion — 
which  I  have  just  considered — or  to  varicose  veins  of  the 
bladder. 

The  bleeding  may  take  place  from  the  free  surface  of  the 
mucous  membrane,  and  mingle  at  once  with  the  urine  or  co- 
agulate in,  the  bladder.  It  may  also  take  place  beneath  the 
surface  of  the  mucous  membrane,  and  form  ecchymoses,  like 
the  spots  seen  beneath  the  skin  in  purpura.  There  is  also  a 
condition  known  as  hemoglobinuria,  in  which  only  the  color- 
ing matter  of  the  blood  is  found  in  the  urine,  no  blood-cor- 
puscles being  present. 

The  quantity  of  blood  varies  greatly  in  diilerent  diseases, 
and  in  the  same  disease  in  different  persons.  In  congestion 
of  the  bladder  blood-globules  will  often  be  found  in  the  urine 
only  upon  microscopic  examination,  while  at  other  times  the 
urine  will  have  the  appearance  of  being  all  blood.  Again, 
the  blood  may  coagulate,  and  be  passed  in  clots,  or  the 
coagula  may  remain  in  the  bladder,  finally  break  down,  and 
be  passed  as  a  chocolate- colored  or  blackish  matter. 

Symptomatology. — The  symptoms  of  haemorrhage  do  not 
differ  from  those  of  congestion  or  the  onset  of  cystitis,  except 
when  small  clots  form,  distending  the  urethra,  and  causing 
pain  in  urinating.  It  is  very  rare  that  bleeding  from  these 
causes  is  sufficient  to  prostrate  the  patient. 

As  bleeding  may  take  place  at  any  point  in  the  urinary 
tract,  it  is  important  always  to  locate  the  hsemorrhage. 
When  coming  from  the  bladder  in  any  quantity,  it  is  usually 
passed  in  small  clots,  and  is  seldom  so  intimately  mixed  with 
the  urine  as  when  it  comes  from  the  kidneys  or  ureters. 
This  statement,  however,  is  not  exact,  and  at  best  gives  but 
a  probable  idea  of  the  true  facts.  To  complete  the  diagnosis, 
we  must  resort  to  something  more  trustworthy.  Sir  Henry 
Thompson  gives  a  very  ingenious  method  for  determining  as 
to  whether  pus  found  in  the  urine  comes  from  the  kidneys  or 


438  MEDICAL  GYNECOLOGY. 

bladder,  and  Van  Buren  and  Keyes  advise  the  same  plan  for 
detecting  the  source  of  hgemorrhage. 

The  method  is  this  :  "A  soft  catheter  is  gently  introduced 
first  within  the  neck  of  the  bladder,  the  urine  drawn  off,  and 
the  cavity  washed  out  very  gently  with  tejDid  water.  If  the 
water  can  not  be  made  to  flow  away  clear,  the  inference  is 
that  the  blood  comes  from  the  cavity  of  the  bladder.  If 
it  flows  away  clear,  then  the  catheter  is  closed  for  a  few 
moments,  the  jDatient  being  at  rest,  and  the  few  drachms  of 
urine  which  collect  may  be  drawn  off  and  examined.  The 
bladder  is  now  again  washed  out,  and  if,  after  a  single  wash- 
ing, the  second  flow  of  injection  is  clear,  while  the  drachm  of 
urine  was  bloody,  the  inference  is  again  complete  that  the 
blood  comes  from  one  or  the  other  kidney." 

When  it  is  known  that  the  patient  has  had  no  kidney 
disease,  nor  symptoms  of  renal  calculi,  it  may  be  inferred 
that  the  blood  comes  from  the  bladder.  Haemorrhage  from 
the  urethra  might  mislead,  but  is  easily  detected  if  it  is  re- 
membered that  in  this  case  bleeding  occurs  between  the  acts 
of  as  well  as  during  micturition.  It  may  also  readily  be  dis- 
covered with  the  endoscope,  provided  the  tube  be  not  too 
large. 

Causation. — The  causes  of  vesical  hgemorrhage  or  cys- 
torrhagia  are :  congestion,  varicose  veins,  villous  cancer, 
lesions  of  structure,  as  in  ulceration  and  sloughing  of  mu- 
cous membrane  from  injury  or  cystitis,  and  obstruction 
to  or  interference  with  the  portal  circulation.  This  may 
possibly  explain  the  fact  that  hgemorrhage  occasionally 
occurs  in  those  suffering  from  malaria.  Perhaps  the  vesical 
hgemorrhage  occurring  in  the  intense  heat  of  summer  in  the 
tropics  may  be  thus  explained.  In  malaria  the  obstruction 
to  the  circulation  through  the  portal  system,  acting  as  a  pre- 
disposing cause,  or  the  intense  congestion  of  all  the  internal 
organs  during  a  chill  or  from  exposure  to  cold,  would  cer- 
tainly tend  to  produce  cystorrhagia. 

In  purpura,  the  eruptive,  typhus,  and  typhoid  fevers, 
bleeding  from   the  bladder  may  occur ;   but,   as  it  is  here 


ORGANIC  DISEASES  OP  THE  BLADDER.  439 

secondary  to  the  main  disease,  nothing  need  be  said  about  it 
in  this  connection. 

The  most  marked  predisposing  cause  of  cystorrhagia  in 
women  is  the  hsemorrhagic  diathesis,  which  is  not  uncommon 
among  chlorotic  subjects. 

Treatment. — The  treatment  must  largely  depend  on  the 
cause.  In  all  cases  rest  in  the  recumbent  position  should 
be  insisted  upon.  A  large  number  of  haemostatics  have  been 
recommended,  and  some  of  them— such  as  aromatic  sulphuric 
acid,  tannic  and  gallic  acids,  in  moderate  doses — are  doubtless 
of  some  value.  I  have,  however,  depended  chiefly  on  doses 
of  conium  sufficiently  large  to  quiet  the  desire  to  urinate, 
and  alkaline  diluents  to  render  the  urine  non-irritant  when 
it  was  found  to  be  excessively  acid.  Hydrastis  canadensis, 
and  ergot,  singly  or  combined,  I  have  found  useful. 

When  the  haemorrhage  is  so  free  as  to  excite  fears  of 
prostration,  ice  may  be  employed.  Small  smooth  pieces 
should  be  introduced  into  the  vagina  at  regular  intervals  as 
long  as  the  patient  can  comfortably  bear  it.  Ice  may  also  be 
applied  to  the  hypogastrium. 

When  the  blood  coagulates  and  forms  a  large  clot  in  the 
bladder,  it  should  be  allowed  to  remain  until  it  breaks  down 
and  comes  away  of  itself.  The  experience  of  surgeons  is  that 
there  is  much  more  danger  in  attempting  to  remove  the  clot 
than  in  letting  it  alone.  There  are  two  dangers  in  removing 
coagula  from  the  bladder.  One  is,  that  doing  so  will  almost 
certainly  start  the  bleeding  again  ;  and  the  other  is,  the 
liability  to  injure  the  bladder  and  cause  inflammation.  Let 
the  clots  take  care  of  themselves,  keeping  the  patient  quiet 
and  comfortable  (with  opium,  if  possible)  until  the  coagula 
are  disposed  of.  Limewater  has  been  recommended  as  a 
solvent  of  blood-clots  by  Dr.  J.  H.  Ledlin,  of  Pittsfield,  Illi- 
nois, and  it  seems  to  have  acted  well. 

Allusion  has  been  made  to  varicose  veins  of  the  bladder, 
by  some  called  "haemorrhoids  of  the  bladder."  This  con- 
dition is  chiefly  found  in  pregnant  women,  especially  those 
who  have  borne  several  children.     The  cause  is  interruption 


440  MEDICAL  GYXECOLOGT. 

of  the  venous  circulation  by  pressure  of  tlie  gravid  uterus. 
The  veins  of  the  anterior  vaginal  wall,  introitus  vulvae,  and 
labia  will  often  be  found  in  the  same  condition.  Occasion- 
ally prolapsus  of  the  bladder  will  also  be  found. 

This  affection  gives  rise  to  those  symptoms  of  pelvic  dis- 
tress and  frequent  urination  that  are  so  troublesome  in  some 
pregnant  women.  It  must  be  kept  in  mind,  however,  that 
the  same  symptoms  may  come  from  pressure,  which  does  not 
produce  varicose  veins.  If  it  is  found  that  the  urine  is  nor- 
mal, and  the  patient  feels  relieved  to  some  extent  in  the  re- 
cumbent position,  this  trouble  may  be  susjDected,  and,  if  the 
indications  are  sufficiently  urgent,  a  local  examination  should 
be  made  which  will  reveal  a  varicose  condition  of  the  vessels 
of  the  urethra  and  vaginal  walls,  and  from  this  it  may  be 
inferred  that  the  same  condition  exists  in  the  bladder. 

This  disorder  is  relieved  or  passes  off  altogether  after  con- 
finement, and  usually  the  best  that  can  be  done  is  to  give 
rest  and  try  to  make  the  patient  comfortable  until  the  end  of 
her  ' '  term. " 

Should  the  trouble  continue  after  delivery,  especially  if 
there  is  cystocele  or  prolapsus  of  the  bladder,  much  good 
may  be  done  by  restoring  and  keeping  the  organ  in  place. 
This  can  best  be  accomplished  by  using  the  cotton  pessary 
or  a  roll  of  marine  lint  packed  loosely  into  the  vagina,  like 
a  tampon.  The  patient  can  be  instructed  to  use  this  herself. 
Attention  should  be  given  to  the  general  health,  and  par- 
ticularly to  the  state  of  the  bowels  and  portal  circulation. 
Rest  in  bed,  and  the  use  of  cool  water  as  a  vaginal  injec- 
tion, may  also  be  of  service. 

Should  haemorrhage  occur  from  this  condition  of  the 
veins,  it  may  be  treated  as  described  in  the  discussion  of  that 
subject. 


CHAPTER   XXXyi. 

CYSTITIS. 

Cystitis  is  mucli  more  common  among  women  tlian  is 
generally  supposed.  It  is  necessary,  therefore,  to  inquire 
carefully  into  the  aetiology,  pathology,  and  therapeutics  of 
this  malady,  which  causes  great  suffering  on  the  part  of  the 
patient,  and  taxes  the  highest  skill  of  the  ablest  physicians 
and  surgeons. 

To  the  several  forms,  grades,  or  degrees  of  this  disease 
various  names  have  been  given,  such,  as  acute,  subacute,  and 
chronic  cystitis,  cystitis  mucosa  (catarrh  of  the  bladder),  in- 
terstitial cystitis,  pericystitis  and  epicystitis,  and  croupous, 
diphtheritic,  and  gonorrhoeal  cystitis.  This  medley  of  names 
should  not  be  allowed  to  lead  to  confusion,  but  this  fact 
should  be  firmly  fixed  in  the  mind  :  that,  with  the  exception 
of  the  last  three  (the  aetiology  and  pathology  of  which  are 
somewhat  different),  they  are  all  simply  steps  or  stages  in  one 
general  process.  Thus  a  patient  may  have  received  an  injury 
of  the  bladder  by  the  use  of  a  catheter,  causing  an  acute  cys- 
titis. This  may  end  in  convalescence,  or  merge  slowly  into 
the  more  chronic  form,  having,  very  likely,  as  an  intermediate 
stage,  catarrhal  cystitis.  This,  too,  may  go  on  to  recovery ; 
but,  if  the  process  extends  and  its  severity  increases,  ulcer- 
ation takes  place,  and  the  submucous  and  intermuscular  tis- 
sues become  involved,  producing  interstitial  cystitis.  If  the 
inflammation  extends  still  further,  and  involves  the  serous 
coat  of  the  bladder,  either  by  extension  or  ulceration,  with 
or  without  perforation,  pericystitis  or  epicystitis  appears.  I 
tope  I  have  thus  made  clear  the  fact  that  names  are  only 

441 


442  MEDICAL  aYNECOLOGY. 

given  to  denote  the  degree  of  intensity  of  the  inflammatory 
process,  and  the  character  and  extent  of  the  tissue  involved. 

Inflammation  of  the  mucons  membrane  alone  is  by  far  the 
most  common  form,  and  hence,  in  using  the  term  cystitis, 
reference  is  usually  made  to  inflammation  of  that  membrane 
only.  When  other  tissues  are  involved,  or  the  character  of 
the  disease  is  peculiar,  some  qualifying  word  is  added  to  dis- 
tinguish it. 

The  existence  of  acute  inflammation  of  the  bladder  other 
than  that  due  to  local  causes  is  emphatically  denied  by  many 
authors.  The  statements  made  are  usually  too  broad  and 
sweejnng  to  be  sustained  by  the  facts  observed  in  actual 
practice.  I  believe  that  cases  of  acute  cystitis  from  exposure 
to  cold,  wet,  and  other  causes  do  occur.  It  must,  however, 
be  admitted  that  such  instances  are  very  rare,  and  some  that 
have  been  considered  as  acute  idiopathic  cystitis  may  have 
been  but  a  development  of  acute  inflammatory  disease  from  a 
pre-existing  abnormal  condition. 

It  is  also  possible  that  those  who  deny  the  existence  of 
acute  idiopathic  cystitis  may  base  their  belief  upon  the  fact 
that  in  what  is  called  acute  inflammation  of  the  bladder  all 
the  phenomena  of  well-defined  inflammation  are  not  present, 
while  others  consider  hypersemia  of  the  mucous  membrane 
and  derangement  of  bladder  function  all  that  is  necessary  to 
constitute  a  cystitis.  Thus  the  apx^arently  different  opinions 
that  exist  among  authors  upon  this  subject  may  arise  from 
conflicting  views  as  to  what  really  constitutes  inflammation. 

I  prefer  to  class  this  condition  (of  congestion,  hypersecre- 
tion of  mucus,  abnormal  exfoliation  of  epithelium,  and  irri- 
tability) among  the  inflammatory  affections,  and  call  it  acute 
cystitis.  Such  an  affection  as  this  is  met  with  in  every-day 
practice,  and  I  know  of  no  better  name  for  it. 

Pathology . — As  acute  cystitis  soon  terminates  in  resolu- 
tion, or  merges  gradually  into  chronic  cystitis,  I  think  it  best 
to  give  the  pathology  of  both  diseases  at  once,  they  being,  as 
I  have  already  said,  simply  different  in  degree  of  intensity 
and  duration. 


CYSTITIS.  44,3 

The  morbid  anatomy  of  cystitis  is  the  same  as  that  of  in- 
flammation of  mucous  membranes  in  other  parts  of  the  body. 
In  the  more  acute  forms  the  membrane  is  swollen  and  re- 
laxed and  of  a  bright  or  deep  red  color,  from  hypersemia. 
The  surface  is  partially  or  entirely  covered  with  a  thick, 
tenacious  mucus.  There  is  exfoliation  of  the  eijithelium,  as 
shown  by  the  partially  denuded  condition  of  the  membrane, 
especially  at  the  top  of  the  rugse,  and  pus  and  loose  cells  are 
found  in  the  sulci  between  the  folds. 

In  some  instances,  especially  in  cases  of  acute  cystitis 
resulting  from  extreme  overdistention  due  to  mechanical  or 
other  causes  of  retention,  the  whole  or  only  a  part  of  the 
mucous  membrane  of  the  bladder  may  slough  or  separate  and 
be  thrown  off.  This  is  more  apt  to  occur  when  the  retention 
and  overdistention  are  caused  by  accidents  of  the  puerperal 
state  or  during  delivery.  That  the  separation  of  the  mucous 
membrane  is  not  due  to  direct  injury  caused  by  the  child's 
head  or  instruments  carelessly  used,  but  to  the  effect  of  over- 
distention, is  shown  by  the  fact  that  the  vesical  neck,  which 
is  subject  to  the  most  direct  injury,  seldom  shows  sei)aration 
of  its  mucous  membrane.  That  injury  to  the  organ  may  pre- 
dispose to  separation,  or  even  determine  it  when  already 
predisposed  to  it  by  some  other  cause,  there  can  be  no  doubt. 
Most  of  these  cases  of  separation  of  the  mucous  membrane 
have  occurred  in  women,  and  almost  all  followed  delivery. 
The  bladder  which  has  participated  in  the  general  congestion 
of  the  pelvic  organs,  incident  to  the  puerperal  state,  is  in  a 
condition  to  respond  to  injuries  causing  such  separation  to 
take  place. 

The  manner  of  its  production  is  probably  as  follows :  A 
woman  at  full  term  is  delivered  of  a  healthy  child  after  a 
long  and  tedious  labor,  with  or  without  the  use  of  instru- 
ments. The  child's  head  or  the  forceps  may  have  done  vio- 
lence to  the  urethral  mucous  membrane  by  crowding  the  ure- 
thra against  the  unyielding  pubic  bones.  Swelling  of  the 
mucous  membrane  results,  and  retention  of  urine  (if  the  pa- 
tient be  not  relieved  by  the  catheter)  follows  and  persists  for 

29 


4:M  •         MEDICAL  GYNECOLOGY. 

a  varying  length  of  time.  The  doctor,  the  nurse,  and  the 
patient  herself  are  often  led  to  believe,  from  the  constant 
or  intermittent  dribbling  of  urine,  that  there  is  an  irritable 
condition  of  that  organ,  with  incontinence.  The  truth  is, 
that  this  dribbling  (stillicidium)  is  almost  a  certain  sign  of 
an  overdistended  bladder,  and  if  the  patient  is  not  relieved 
the  distention  will  gradually  increase.  The  organ  having 
reached  its  limit  of  distention,  or  being  stretched  to  its  ut- 
most, the  pressure  within  is  so  great  as  to  cut  off  the  sup- 
ply of  blood  to  the  submucous  tissue,  and  thus  to  the  mucous 
membrane  itself.  This  is  more  readily  accomplished,  as  the 
muscular  fibers  are  pulled  apart  and  the  mucous  membrane 
thereby  allowed  a  certain  amount  of  bulging,  by  which  its 
blood  supply  is  seriously  interfered  with.  If  the  distention 
be  relieved  early  enough,  nothing  worse  than  an  acute  cys- 
titis results  ;  but  if  not  relieved,  death  of  the  whole  or  part 
of  the  membrane  occurs,  and  it  is  sooner  or  later  thrown  off. 

This  ailment  is  not  a  common  one,  and  though  cases  may 
seldom  be  met,  I  desire  to  lay  stress  upon  the  great  impor- 
tance of  paying  strict  and  individual  attention  to  the  condi- 
tion of  the  urinary  organs  in  pregnant  and  parturient  women. 
The  catheter  can  tell  more  of  the  condition  of  the  patient's 
bladder  in  such  cases  than  any  nurse,  and  can  do  no  harm 
whatever  when  a  clean  soft  instrument  is  used  with  care. 

Symptomatology. — The  various  forms  of  cystitis  being  sim- 
ply stages  of  the  same  disease,  I  shall  speak  of  their  symptoms 
all  under  one  head. 

They  may,  for  convenience'  sake,  be  divided  as  follows : 
1.  Symptoms  referable  to  the  organ  or  its  contents.  2.  Symp- 
toms referable  to  neighboring  organs,  that  suffer  either  from 
sympathy  or  through  direct  extension,  3.  Symptoms  refer- 
able to  various  conditions  of  the  general  system,  as  {a)  The 
vascular  system.  (&)  The  digestive  tract,  (c)  The  cutaneous 
surface,     {d)  The  nervous  system — cephalic  and  subcephalic. 

1.  The  symptoms  referable  to  the  organ  itself  are  chiefly 
derangement  of  function — viz.,  pain,  tenesmus,  and  frequent 
urination.     The  indications  vary  in  severity  according  to  the 


CYSTITIS.  445 

extent  and  intensity  of  the  cystitis.  In  the  mildest  form  of 
the  trouble  there  is  frequent  desire  to  pass  water,  which  often 
comes  with  unusual  force.  Micturition  is  followed  by  a  desire 
to  strain,  called  vesical  tenesmus,  as  if  the  organ  had  not  been 
fully  emptied.  In  the  more  acute  cases  this  gives  rise  to  the 
most  intense  agony,  the  patient  remaining  on  the  vessel  for 
hours  at  a  time.  The  sensation  of  a  few  drops  of  urine  re- 
maining in  the  bladder  may  pass  off  in  a  few  moments,  but, 
as  a  rule,  retjirns  after  each  micturition. 

The  condition  of  the  urine  in  acute  cystitis  is  of  impor- 
tance, but  if  reliance  is  placed  upon  it  alone  for  a  diagnosis 
there  will  be  many  disappointments.  In  the  primary  acute 
form  the  gravity  is  little  if  anything  below  the  normal,  and  if 
there  is  marked  fever,  may  rise  as  high  as  1030.  In  acute 
attacks  ingrafted  on  a  chronic  state,  the  gravity  is  usually 
low.  When  the  specific  gravity  is  low  in  acute  cystitis,  if 
not  dependent  on  the  diluent  drinks  and  diuretics  given,  it 
is  probably  due  to  a  slight  sympathetic  hypersemia  of  the 
kidneys. 

The  reaction  of  the  urine  when  the  affection  is  not  due  to 
or  accompanied  by  retention  is  at  first  usually  acid.  If  there 
be  retention,  the  reaction  is  usually  alkaline,  due  partly  to 
the  fixed  alkali  of  the  mucus  which  is  present  in  excess,  but 
chiefiy  to  the  ammonia  disengaged  in  the  breaking  down  of 
the  urea.  The  color  is  but  slightly  altered.  The  presence  of 
a  little  blood  may  give  to  the  urine  a  smoky  tint,  and  if  de- 
composed it  will  look  hazy,  and  perhaps  contain  sparkling 
crystals  of  the  triple  phosphate.  In  the  chronic  form  the 
urine  is  of  a  pale,  dirty-yellow  hue,  and  may  be  of  a  deep 
red,  from  the  presence  of  considerable  blood.  The  odor  is  of 
an  ammoniacal  type  if  the  urine  be  decomposed  ;  otherwise  it 
is  normal.  It  has  not  only  an  ammoniacal  but  a  peculiar 
pungent  odor  of  flesh.  This  is  usually  known  as  organic^ 
from  the  fact  that  it  is  due  to  the  amount  of  organic  mate- 
rial present. 

The  sediment  in  acute  cystitis  is  usually  mucus,  some- 
times pus  (white  and  clinging  to  the  bottom,  or  somewhat 


446  MEDICAL  GYNECOLOGY. 

flocculent).  It  may  be  tinged  with  blood,  or  rendered  denser 
and  whiter  from  the  presence  of  the  amorphous  and  triple 
phosphates.  In  chronic  cystitis  the  sediment  is  commonly 
heavy  and  of  a  dirty-brown  or  brownish-yellow  color.  Flakes 
of  pus,  shreds  of  tissue,  as  well  as  blood  and  epithelial  ele- 
ments, cause  it  to  vary  greatly  in  different  cases.  When  the 
intense  alkalinity  of  the  urine  has  rendered  the  pus  gelati- 
nous, the  sediment  is  seen  as  a  ropy  mass  that  clings  tena- 
ciously to  the  bottom  of  the  vessel.  Microscopically,  this  sedi- 
ment presents  a  varied  and  interesting  appearance.  In  the 
acute  form  numerous  fibrillse  of  mucus,  a  few  pus-corpuscles, 
and  possibly  blood-globules  are  to  be  seen,  and,  if  decomposi- 
tion has  taken  place,  the  amoriDhous  and  triple  phosphates. 

Upon  testing  the  urine  chemically,  albumin  will  be  found 
in  proportion  to  the  amount  of  pus  or  blood  present.  If 
renal  disease  coexist,  the  amount  of  albumin  will  be  greatly 
increased. 

2.  Symptoms  referable  to  neighboring  organs :  These  are 
not  especially  marked.  In  some  cases,  with  the  intense  vesical 
tenesmus,  there  may  exist  an  irritable  condition  of  the  rectum, 
with  some  tenesmus  and  pain  at  stool.  The  uterus  is  often 
congested,  which  causes  a  free  leucorrhcea  ;  subinvolution  fre- 
quently occurs  after  the  confinement  of  those  who  have  had 
cystitis  during  pregnancy.  Extension  of  the  inflammation 
in  extreme  cases  may  cause  metritis  and  pelvic  cellulitis  and 
peritonitis.  This  only  takes  place  in  old  cases.  The  symp- 
toms thus  arising  will  be  characteristic  of  the  disease  of  the 
organs  or  tissues  involved. 

Menstruation  may  be  variously  disturbed ;  menorrhagia, 
metrorrhagia,  or  amenorrhcea,  resulting  either  from  conges- 
tion, inflammatory  extension,  or  reflex  nervous  influence,  may 
occur.  Neuralgia  of  the  uterus  or  ovaries  may  also  be  pro- 
duced in  this  way.  I  have  just  said  that  subinvolution  of  the 
uterus  is  almost  sure  to  follow  a  pregnancy  occurring  during 
the  existence  of  a  vesical  inflammation,  and  I  am  inclined  to 
believe  that  the  same  result  is  produced  in  some  cases  by  an 
acute  cystitis  following  delivery. 


CYSTITIS.  447 

3,  Symptoms  referable  to  disturbances  of  tlie  general  sys- 
tem :  These  symptoms  may  be  due  to  reflex  nervous  influ- 
ence.    For  convenience'  sake  I  shall  flrst  consider — ■ 

{a)  The  Vascular  System. — There  is  not,  as  a  rule,  much 
disturbance  of  the  correct  action  in  acute  cystitis.  Although 
there  has  been  much  dispute  among  authors  as  to  how  and 
by  what  means  the  general  poisoning  is  caused,  there  seems 
to  be  no  question  as  to  whether  such  a  poisoning  really  does 
take  place.  ^  General  systemic  efl'ects  may  be  produced  by 
two  separate  blood  conditions.  They  are,  first,  abnormal  in- 
gredients existing  in  the  blood,  and,  second,  a  poor  condition 
of  the  blood  itself  (anaemia). 

(&)  The  Digestive  Tract. — Anorexia,  especially  at  the 
morning  meal,  is  a  common  accompaniment  of  chronic  cys- 
titis. In  some  cases  this  is  the  only  meal  where  the  appetite 
does  not  invite  the  patient  to  partake.  A  longing  for  peculiar 
foods  is  also  very  common,  the  patient  often  having  lost  the 
desire  before  the  article  in  question  reaches  her.  The  com- 
mon symptoms  of  disordered  digestion  are  usually  joresent, 
and  the  affection  may  be  either  of  the  nervous  type  or  of  the 
chronic  catarrhal  form,  though  it  is  usually  a  mixture  of  both. 
If,  as  is  believed,  the  poisonous  material  absorbed  from  the 
bladder  and  the  non-eliminated  urinary  salts  find  vent  through 
the  alimentary  canal,  we  have  no  trouble  in  discovering  a 
cause  for  the  catarrhal  disorder.  The  nervous  disorders  are 
readily  explained  by  the  effects  of  the  abnormal  condition  of 
the  blood,  and  the  broken  and  sleepless  nights  which  inter- 
rupt and  retard  the  nutrition  of  the  nervous  system. 

The  bowels  are  usually  irregular  and  constipated,  and  re- 
quire laxatives  or  daily  enemata  to  open  them.  In  chronic 
cases  this  costiveness  is  occasionally  interrupted  by  a  profuse 
watery  diarrhoea,  which  would  seem  to  be  an  effort  of  Nature 
to  relieve  the  blood  of  its  abnormal  contents,  as  I  have 
already  said.  It  may  last  for  days  or  only  for  a  few  hours, 
and  the  discharges  are  usually  rich  in  the  carbonate  of 
ammonia.  The  septicsemic  diarrhoea  differs  usually  in  the 
great  prostration  accompanying  it,  the  character  of  the  stools 


448  MEDICAL  GYNECOLOGY. 

(black  or  greenisli  black,  and  very  offensive,  the  organic  odor 
quite  or  partly  hiding  the  ammoniacal  odor),  and  the  fact 
that  it  is  usually  preceded  or  accompanied  by  chills,  fever,  and 
sweating.  If  checked  too  abruptly,  head  symptoms,  mild 
muttering  delirium,  etc.,  are  likely  to  follow. 

The  results  of  imperfect  digestion  are  seen  in  the  poor, 
unhealthy  condition  of  the  patient's  flesh  and  skin,  and  all 
the  signs  of  malnutrition  present. 

(e)  The  Cutaneous  Surface. — The  skin  of  patients  with 
chronic  cystitis  is  usually  sallow,  loose,  and  has  a  lifeless  feel. 
Indeed,  one  might  almost  make  a  diagnosis  from  the  com- 
plexion alone.  Sweating  of  the  palms  of  the  hands  and  soles 
of  the  feet  is  common.  In  low  states  of  the  system  the  pa- 
tients are  especially  liable  to  night  sweats,  and  the  perspira- 
tion sometimes  has  a  urinous  odor.  I  have  already  spoken 
of  the  septicsemic  diaphoresis. 

{d)  The  Nervous  System.  — I  shall  first  consider  the  symp- 
toms apj)ertaining  to  the  brain  and  its  function,  and  then  to 
the  subcephalic  nervous  system.  The  brain  symptoms  in  the 
early  stages  of  cystitis  are  not  diagnostic.  They  are  the  same 
as  come  from  pain  and  loss  of  sleep  from  any  cause,  increased 
irritability,  and  depression  from  weakness. 

There  is  a  peculiar  brain  condition,  supposed  by  some  to 
be  caused  by  cerebral  anaemia  ;  others  attribute  it  to  a  pe- 
culiar poison  circulating  in  the  blood.  By  anaemia  of  the 
brain  in  this  connection  is  meant  not  only  lack  of  blood  in 
that  organ,  but  an  exceedingly  impoverished  condition  of  the 
blood  circulating  there.  Those  remedies  that  tend  to  lessen 
the  amount  of  blood  in  the  brain,  as  bromide  of  potassium 
and  ergot,  produce  most  unpleasant  symptoms  in  these  cases, 
such  as  dizziness  and  fainting.  Medicines  which  act  in  a 
manner  to  congest  the  brain,  if  given  in  small  doses,  improve 
this  condition,  as  also  do  the  ferruginous  tonics,  especially 
iron  by  hydrogen.  From  this  it  would  appear  that  this  pecul- 
iar condition  is  due  more  to  the  amount  and  imperfect  con- 
stitution of  the  blood  circulating  in  the  brain  than  to  the  ab- 
sorbed or  non-eliminated  abnormal  matter. 


CYSTITIS.  4-49 

Diagnosis. — The  diagnosis  of  cystitis  is  generally  easy  in 
marked  cases,  but  in  mild  attacks  care  is  necessary  to  distin- 
guish it  from  other  conditions  that  cause  similar  symptoms. 

Frequent  urination  occurs  in  many  other  troubles,  such  as 
prolapsus  uteri,  adhesions  from  pelvic  peritonitis,  abdominal 
tumors,  and  in  various  neuroses.  Pregnancy,  also,  some- 
times gives  rise  to  an  annoying  frequency  of  the  act.  That 
arising  from  prolapsus  is  worse  when  the  patient  is  standing 
or  walking,  and  is  relieved  wholly,  or  to  a  great  extent,  by 
the  recumbent  position  ;  while  in  cystitis,  position  makes  no 
marked  difference. 

I  have  seen  one  very  interesting  exception  to  this  general 
rule.  The  patient  had  a  complete  X->rolapsus  for  many  years, 
and  when  in  the  erect  position  she  could  retain  the  urine  for  an 
ordinary  length  of  time,  but  when  she  was  reclining  the  most 
urgent  desire  to  urinate  came  on,  and  she  could  only  retain  a 
very  small  quantity  of  urine.  The  cause  of  this  I  found  to  be 
inJlammation  of  the  neck  of  the  bladder.  When  in  the  upright 
position  the  urine  settled  down  in  the  dependent  portion,  but 
while  recumbent  the  pressure  came  on  the  tender  part. 

In  adhesions  from  pelvic  peritonitis,  abdominal  tumors, 
and  pregnancy,  the  desire  to  urinate  only  comes  on  when  the 
bladder  is  partly  filled,  and  is  about  the  same  day  and  night. 
Frequency  of  urination  is  not  usually  accompanied  by  tenes- 
mus, except  when  due  to  cystitis.  In  the  various  forms  of 
vesical  neuroses  frequent  urination  is  very  irregular,  the  pa- 
tient at  times  being  almost  entirely  free  from  it,  and  at  other 
times  very  much  troubled. 

The  frequent  and  x^ainful  urination  of  cystitis  may  be 
simulated  by  urethritis  and  other  painful,  irritable  condi- 
tions of  the  urethra.  The  distinction  can  be  made,  usually, 
from  the  fact  that  in  urethral  disease  there  is  no  vesical  tenes- 
mus, or,  if  any,  it  is  much  less  than  in  cystitis.  There  are 
acute  pain  in  the  act  of  urination  and  a  burning  sensation  in 
the  urethra,  which  sometimes  cause  sympathetic  vesical  tenes- 
mus ;  but  when  this  latter  passes  off,  the  bladder  will  tolerate 
distention  to  the  fullest  extent. 


450  MEDICAL  GYNECOLOGY. 

The  urine  should  be  carefully  examined  and  the  resnlts 
as  carefully  considered.  Implicit  dependence,  however,  must 
not  be  placed  on  the  condition  of  the  urine.  Acate  or  chronic 
congestion  may  produce  considerable  mucus  that  is  some- 
times mistaken  for  pus  that  has  become  gelatinous  by  the 
action  of  strong  alkali.  Pus  may  be  present  in  the  urine 
from  suppuration  of  the  upper  urinary  passages  (pyone- 
phrosis, renal  abscess,  and  pyelitis),  or  from  abscesses  of 
neighboring  organs  or  tissues  opening  into  the  bladder,  as  in 
colitis  and  pelvic  cellulitis.  When  there  is  doubt  on  this 
point.  Sir  Henry  Thompson's  method  of  procedure,  as  recom- 
mended by  Van  Buren  and  Keyes,  for  detecting  the  source  of 
blood  should  be  tried. 

A  differential  diagnosis  between  cystitis  and  pyelitis  by 
means  of  the  urine  alone  is  almost  an  impossibility,  espe- 
cially in  the  later  stages  of  the  former.  Thompson's  method, 
the  endoscope,  and  the  presence  or  absence  of  a  tumor  in 
the  loins,  with  the  general  symptoms,  must  be  the  guides. 
'No  dependence  can  be  placed  on  the  epithelium,  as  tran- 
sitional forms  from  the  bladder  are  very  likely  to  be  mis- 
taken for  the  normal  epithelium  of  the  renal  pelves,  and  lead 
to  error. 

To  make  a  positive  and  reliable  diagnosis,  resort  must  be 
had  to  physical  exploration  of  the  organ.  The  methods  of 
exploration  are  palpation,  percussion,  and  auscultation  of 
the  abdomen ;  examination  of  all  the  pelvic  organs  by  the 
touch  and  speculum ;  and,  lastly,  exploration  of  the  bladder 
by  the  catheter  or  sound. 

By  palpation  and  percussion  of  the  abdomen,  tenderness 
and  distention  of  the  bladder  may  be  detected,  if  either 
exist.  By  the  same  means  it  may  be  ascertained  whether 
the  bladder  is  contracted  and  its  walls  thickened,  rigid,  or  re- 
laxed. Auscultation  will  possibly  reveal  friction  sounds  in 
cases  w^here  inflammation  has  extended  to  the  serous  coat, 
and  caused  roughening  by  exudation  on  the  peritoneal  sur- 
faces. These  may  seem  to  be  rather  delicate  points  in  exam- 
ination, but  in  obscure  cases  one  must  use  all  the  means  that 


CYSTITIS.  451 

can  give  the  slightest  evidence.  Examination  of  the  pelvic 
organs  by  touch  will  detect  any  disease  of  these  that  may 
either  cause  or  complicate  the  cystitis.  Displacements  and 
inflammatory  affections  of  the  uterus,  vagina,  or  rectum,  pel- 
vic peritonitis,  or  the  products  of  a  former  attack  of  that 
disease,  ovarian  diseases,  and  tumors,  should  be  carefully 
sought  for,  and,  if  present,  their  relations  to  the  vesical 
trouble  carefully  studied. 

Cystitis,  produced  by  or  producing  pelvic  cellulitis  and 
peritonitis  has  the  same  symptoms  as  ordinary  purulent  vesi- 
cal inflammation,  plus  those  of  well-defined  pelvic  inflamma- 
tion. There  are  usually  pain  and  tenderness  of  the  pelvic 
organs,  and  the  symptomatic  fever  of  local  inflammation. 

In  those  cases  where,  from  gluing  together  of  the  pelvic 
organs,  the  bladder  walls  are  separated  and  kept  upon  the 
stretch,  incontinence  often  results,  sometimes  overdistention 
with  dribbling.  In  such  forms  the  cystitis  may  be  entirely 
secondary  to  the  pelvic  adhesions,  and  consequent  vesical  dis- 
tention. The  urethra  should  be  examined  with  care,  for 
some  of  its  diseases  present  a  natural  history  closely  resem- 
bling that  of  some  vesical  affections. 

By  a  careful  use  of  the  catheter  or  sound  introduced  into 
the  bladder,  the  degree  of  tenderness  of  that  organ  can  be  de- 
termined, and  the  presence  of  foreign  bodies,  such  as  a  stone 
in  the  bladder,  can  be  excluded.  The  sound  being  in  the 
bladder,  the  finger  may  be  introduced  into  the  vagina,  and 
the  posterior  and  inferior  walls  be  examined  as  to  their  thick- 
ness and  tenderness. 

In  suspected  cystitis  the  neck  of  the  bladder  ought  always 
to  be  examined  with  a  view  of  detecting  ulceration  and  fis- 
sures at  that  point.  These  fissures  give  rise  to  symptoms 
very  closely  simulating  cystitis,  and  the  differential  diagnosis 
can  only  be  made  by  the  endoscope.  This  instrument  affords 
the  only  means  of  ascertaining  the  exact  appearance  of  the 
interior  of  the  bladder.  All  chronic  and  complicated  cases 
requiring  a  physical  exploration  belong  to  the  surgeon,  and 
what  has  been  said  on  the  subject  is  given  to  guide  the  physi- 


452  MEDICAL  GYNECOLOGY. 

cian  in  determining  the  limits  of  his  ability  to  care  for  given 
cases. 

I  have  called  attention  to  the  fact  that  surgical  treatment 
is  often  injurious,  and  that  many  cases,  especially  the  acute 
forms,  are  better  managed  by  the  physician  than  by  the  sur- 
geon. I  must  here  say  that  chronic  and  complicated  cases 
should  at  once  be  placed  in  the  care  of  a  competent  surgeon. 

Causation. — The  cause  of  acute  cystitis  may  for  conven- 
ience be  classed  under  live  heads,  each  of  which  will  be 
studied  separately : 

1.  Direct  injuries,  such  as  blows  in  the  vesical  region, 
falls,  fractures  of  the  pelvic  bones,  violent  coiDulation,  sud- 
den uterine  displacements  and  i^ressure  therefrom,  contu- 
sions and  injuries  during  labor,  foreign  bodies,  rough  cathe- 
terization, and  overdistention  from  retention  of  urine. 
2.  Abnormal  urine.  3.  Inflammation  of  adjacent  organs. 
4.  Constitutional  diseases.  5.  Drugs,  improper  food,  and 
the  virus  of  gonorrhoea. 

These  causes  also  pertain  to  chronic  cystitis,  whether  it 
begins  as  an  acute  or  subacute  affection. 

1,  Direct  Injuries. — Blows  over  the  vesical  region,  falls, 
and  especially  fracture  of  the  pelvic  bones,  caused  by  some 
great  force,  usually  produce  acute  inflammation  of  the  blad- 
der,  with  or  without  rupture  of  that  organ.  The  bladder, 
when  full,  is,  of  course,  more  readily  ruptured  than  when 
empty,  rupture  in  the  latter  condition  being  almost  an  im- 
possibility. This  item  of  knowledge  can  be  turned  to  prac- 
tical use  in  traveling,  either  by  rail  or  water,  by  remember- 
ing to  frequently  empty  the  bladder.  In  cystitis  from  severe 
and  direct  injury,  even  without  any  perceptible  traumatic 
lesion  of  the  mucous  membrane,  there  is  apt  to  be  marked 
haemorrhage — much  greater,  indeed,  than  in  cystitis  from 
other  causes. 

Sudden  displacement  of  other  pelvic  organs,  as  the  uterus, 
may  act  in  two  ways  :  first,  by  x^ressure  on  the  bladder,  or  by 
dragging  it  out  of  place  ;  second,  by  blocking  the  urethra  by 
pressure.     These  displacements  may  be  due  to  falls  or  blows, 


CYSTITIS.  453 

and  it  is  not  an  uncommon  occurrence  for  tlie  gravid  uterus 
to  topple  over  by  its  own  w^eiglit.  Supposing  a  retroversion 
of  the  gravid  uterus,  the  cervix  would  crowd  the  urethra 
against  the  pubes,  while  the  utero-vesical  ligament  would 
drag  the  upper  part  of  the  bladder  downward  and  backward. 
Even  after  the  uterus  has  been  replaced,  and  the  pressure  on 
the  urethra  removed,  with  relief  of  the  vesical  overdistention, 
the  retention  is  likely  to  persist,  and  overdistention  recur,  for 
by  the  pressure  the  urethra  becomes  much  tumefied,  and  the 
muscular  and  elastic  tissue  of  the  vesical  walls  overstretched 
and  partly  paralyzed.  If  the  distention  has  been  great  and 
prolonged,  there  may  be  partial  or  total  sloughing  of  the 
vesical  mucous  membrane.  These  causes  give  rise  to  sec- 
ondary cystitis,  and  such  cases  fall  under  the  care  of  the 
surgeon.  They  are  referred  to  him  to  make  the  aetiology 
complete. 

In  retention  of  urine,  and  consequent  overdistention  of 
the  bladder  during  or  after  labor,  either  from  injury  or  care- 
lessness, acute  cystitis  is  very  apt  to  occur.  Here  injury  of 
a  serious  nature  may  be  done  to  the  urethra  by  pressure 
against  the  pubic  bones  by  the  child's  head,  with  or  without 
the  intervening  soft  cushion  of  the  anterior  uterine  lij).  This 
is  especially  the  case  in  slow,  tedious  labors,  where  the  pres- 
sure is  almost  continuous.  The  soft-rubber  catheter  is  the 
only  one  that  for  years  I  have  used,  for  I  regard  the  old 
female  silver  catheter  as  the  most  dangerous  instrument  I 
have  ever  seen.  It  should  be  discarded  forever.  In  cases 
where  the  bladder  had  been  perfectly  healthy,  and  the  cathe- 
ter passed  a  number  of  times  by  way  of  experiment,  the 
points  of  membrane  with  which  the  instrument  had  come  in 
contact  were  abraded  and  congested,  thus  showing  the  danger 
attending  the  unskillful  use  of  this  instrument.  If  the  fre- 
quent introduction  of  it  into  a  healthy  bladder  produces  these 
results,  how  easily  must  the  bladder  of  a  pregnant  woman 
be  inflamed  under  such  treatment,  for  the  organ  has  been 
for  a  time  more  or  less  congested,  and  during  labor  perhaps 
severely  bruised ! 


454:  MEDICAL  GYNECOLOGY. 

The  question  lias  been  raised  as  to  whether  the  irritation 
and  inflammation  following  catheterization  in  some  cases  are 
not  due  to  the  introduction  (during  manipulation)  of  air, 
either  pure  or  containing  germs  that  will  cause  decomposition 
of  the  urine.  The  experiments  of  P.  Dubelt,  in  which  the 
air  was  injected  into  the  bladder,  show  that  it  is  perfectly 
harmless.  Moreover,  the  same  experimenter  found  that  the 
injection  of  decomposing  urine  into  the  bladder  did  little  or 
no  harm,  unless  the  mucous  surface  was  abraded.  What- 
ever may  be  the  effect  of  such  things  on  a  healthy  bladder, 
I  do  not  doubt  but  that  the  introduction  of  germs  by  means 
of  air  or  a  dirty  catheter,  decomposing  urine,  or  the  rough  or 
too  frequent  use  of  a  catheter,  would  produce  an  acute  ex- 
acerbation in  an  organ  already  diseased. 

Forcible  and  excessive  copulation  is  a  positive  exciting  as 
well  as  predisposing  cause  of  acute  or  subacute  cystitis,  and, 
if  persisted  in,  a  chronic  inflammation  of  the  bladder  is  usu- 
ally the  result. 

2.  Abnormal  Urine. — Abnormal  urine  will,  I  think,  excite 
acute  inflammation  in  a  perfectly  healthy  bladder  in  time. 
In  a  bladder,  however,  that  is  suffering  from  chronic  conges- 
tion, in  one  whose  walls  bear  deposits  of  tubercle,  in  cases 
where  some  slight  degree  of  inflammation  already  exists,  then 
abnormal  urine  may  and  does  give  rise  to  marked  inflamma- 
tory trouble.  As  a  rule,  however,  inflammatory  vesical  dis- 
ease precedes  urine  decomposition.  In  cystitis  following  over- 
distention  the  retained  urine,  being  mixed  with  mucus  thrown 
out  by  the  irritated  and  tense  mucous  membrane  to  shield 
itself,  rapidly  decomposes,  and  still  further  aggravates  the 
disordered  condition  of  the  membrane. 

Women,  sometimes  from  a  feeling  of  false  modesty,  more 
often  from  the  lack  of  opportunity,  retain  their  urine  until 
the  bladder  is  distressingly  overdistended,  and  the  urine  par- 
tially decomposed.  Of  course  this  is  wrong,  and  can  gener- 
ally be  avoided,  but  is  nevertheless  a  frequent  cause  of  disease 
of  this  organ. 

Where  there    is   considerable   suppuration  of  the  upper 


CYSTITIS.  455 

nrinary  passages  (renal  abscess,  pyelitis,  or  pyonephrosis), 
the  acid  urine  loaded  with  pus  has,  or  seems  to  have,  an  irri- 
tating effect  on  the  vesical  mucous  membrane,  and  in  some 
instances  probably  induces  a  cystitis,  and  certainly  aggravates 
one  when  already  existing. 

Deposits  of  the  amorphous  phosphate  of  lime,  or  of  the 
ammonio-magnesian  phosphate,  often  greatly  aggravate  and 
render  serious  a  previously  mild  congestion,  but  seldom  if 
ever  produce  acute  inflammation  in  a  healthy  bladder.  The 
same  may  be  said  also  of  uric-acid  gravel  and  other  crystalline 
urinary  sediments,  they  being  at  most  only  able  to  produce 
some  hyperaemia  of  the  membrane  with  a  little  excess  of  the 
mucous  secretion,  but  if  long  continued  will  cause  cystitis. 

To  show  how  some  of  these  causes  may  combine  to  pro- 
duce cystitis,  let  me  take,  for  example,  the  bladder  of  a 
pregnant  woman  which  has  for  some  time  shared  in  conges- 
tion with  the  other  pelvic  organs.  Retention  and  slight  dis- 
tention of  the  bladder  occur  from  some  cause  ;  a  physician 
attempts  to  pass  a  metallic  catheter,  does  it  roughly  and  rap- 
idly, and  relieves  the  viscus  of  its  contents.  A  slight  catarrh 
of  the  raucous  membrane,  the  surface  of  which  is  somewhat 
abraded,  ensues.  By  the  catalytic  action  of  the  mucus  pres- 
ent in  it,  the  urine  is  rapidly  decomposed,  the  process  being 
often  aided  by  germs  introduced  with  the  catheter.  Carbon- 
ate of  ammonia,  having  been  set  free  from  the  broken  down 
urea,  assists  in  alkalizing  the  fluid,  precipitating  the  amor- 
phous phosphates  thereby,  and  forming,  with  the  phosphate 
of  magnesia  already  present,  the  ammonio-magnesian,  or  triple 
phosphate.  The  urine  is  further  alkalized  by  the  alkali  of 
the  mucus.  The  bladder  walls  not  having  fully  regained 
their  tone,  a  little  decomposed  urine  remains  after  each  mic- 
turition, and  aids  in  decomposing  that  which  is  next  secreted. 
The  mucus  increases  in  amount,  the  ammonia  is  more  rapidly 
set  free,  and  the  mucous  membrane  more  and  more  irritated, 
until  a  true  acute  cystitis  is  set  up.  Such  cases  are  of  almost 
daily  occurrence. 

The  decomposed  urine  alone,  however,  produced  without 


456  MEDICAL  GYNECOLOGY. 

the  overdistention  or  without  the  abrasion,  would  not  have 
occasioned  a  true  acute  cystitis,  but  might  possibly,  by  slow 
gradations,  have  worked  up  a  subacute  cystitis.  The  rule,  if 
it  may  be  called  such,  is  the  one  that  I  have  already  given — 
viz.,  that  some  abnormity  of  the  urinary  organs  (as  catarrh) 
almost  invariably  precedes  urinary  decomposition. 

3.  Inflammation  of  Adjacent  Organs. — Acute  cystitis  may 
arise  from  the  extension  of  inflammation  from  neighboring 
organs,  as  in  vaginitis,  metritis,  uterine  and  vaginal  cancer, 
extra-uterine  pregnancy,  abscesses  of  the  colon  or  other 
organs  opening  into  the  bladder,  pelvic  peritonitis,  cellulitis, 
etc.  Gonorrhoea!  inflammation  of  the  urethra  may  extend  to 
the  bladder  ;  but  as  gonorrhoea  of  the  female  urethra  is  com- 
paratively rare,  such  an  extension  is  seldom  seen.  When  it 
does  invade  the  urethra,  it  is  very  apt  also  to  extend  to  the 
bladder,  and  is  very  severe.  Inflammation  of  the  renal  pelves 
and  ureters  may  extend  to  this  organ  and  cause  cystitis,  the 
usual  course,  however,  being  from  the  bladder  to  the  ureters 
and  the  kidneys. 

M.  Eugene  Monod  (Annales  de  Gynecologie,  May,  1880), 
In  discussing  the  question  of  cystitis,  presents  the  following 
conclusions : 

(1)  The  urinary  symptoms  incident  to  pregnancy  proceed 
from  two  different  causes,  to  each  of  which  there  corresponds 
a  distinct  clinical  group  of  symptoms.  The  first  group 
receives  its  explanation  from  the  pressure  produced  by  the 
gravid  uterus,  which  leads  to  retention  of  urine.  The  second 
is  caused  by  vesical  congestion  which  results  from  the  predis- 
position of  the  bladder  to  inflammation,  owing  to  its  close 
vascular  connection  with  the  uterus. 

(2)  During  the  weeks  of  utero-gestation  there  may  occur  a 
variety  of  acute  cystitis  which  is  unquestionably  caused  by 
the  development  of  pregnancy. 

(3)  Immediately  after  or  during  the  first  weeks  following 
normal  delivery  there  may  arise  a  variety  of  cystitis  which, 
owing  to  the  time  of  its  appearance,  deserves  to  be  called 
post-puerperal  cystitis. 


CYSTITIS.  457 

(4)  The  anatomical  relations  between  uterus  and  bladder, 
as  well  as  their  vascular  interconnections,  account  lor  the 
frequency  of  vesical  disorders  accompanying  many  uterine 
maladies.  Certain  physiological  changes  of  the  bladder  dur- 
ing menstruation  and  at  the  time  of  the  menopause  also 
influence  the  establishment  of  bladder  troubles.  Thus  there 
is  seen  to  exist  a  whole  class  of  vesical  inflammations  belong- 
ing only  to  women,  and,  contrary  to  the  generally  accei3ted 
opinion,  cystitis  is  by  no  means  rare  in  women. 

4.  Constitutional  Diseases. — Certain  diseases  of  the  gen- 
eral system  afiiect  the  bladder,  such  as  the  eruptive  fevers. 
In  scarlet  fever,  and  measles  especially,  I  have  noticed  that 
the  mucous  membrane  of  the  bladder  suffers,  to  some  extent, 
like  the  mucous  and  tegumentary  tissues  elsewhere.  Syphi- 
lis is  a  very  potent  cause  of  cystitis,  which  has  not  received 
the  attention  it  deserves.  One  of  the  most  marked  cases  of 
cystitis  that  I  ever  saw  was  caused  by  syphilis,  and  recovered 
under  syphilitic  treatment.  Diseases  of  the  heart  and  liver 
act  more  as  predisposing  causes,  by  producing  chronic  vesical 
congestion,  than  as  exciting  causes,  and  when  they  do  pro- 
duce cystitis  it  is  usually  of  a  low  chronic  type.  Old  age, 
when  the  has  fond  is  greatly  deepened,  acts  more  as  a  predis- 
posing cause  by  allowing  the  collection  and  decomposition 
of  urine.  Paraplegia  and  other  affections  of  like  nature,  by 
permitting  overdistention  and  decomposition,  as  a  rule  pro- 
duce cystitis,  but  of  a  low  form. 

5.  Drugs.,  Improper  Foods,  and  the  Virus  of  GonorrTioea. 
—Of  all  drugs,  cantharides  is  undoubtedly  the  most  active  in 
producing  true  acute  cystitis.  In  many  cases  it  produces 
simple  irritation  and  hypersemia,  stopping  short  of  actual  in- 
flammation. Arsenic  and  turpentine  also  produce  irritation 
and  active  hypersemia,  but  seldom  if  ever  go  further. 

Alcoholic  beverages  persisted  in  for  a  length  of  time  act 
more  as  predisposing  than  as  exciting  causes.  They  may, 
however,  induce  a  low  grade  of  cystitis,  or,  like  the  medi- 
cines given  above,  develop  an  acute  process  in  a  vesical  mem- 
brane already  affected.     Dr.  A.  Jacobi  has  seen  aggravated 


458  MEDICAL  GYNECOLOGY. 

cases  of  cystitis  caused  by  the  free  and  long-continued  use  of 
large  doses  of  the  chlorate  of  potash. 

The  various  foods  can  not  produce  acute  cystitis  in  a 
healthy  bladder,  but  may  aggravate  an  existing  diseased  con- 
dition. The  prohibition,  therefore,  of  stimulating  condi- 
ments— alcohol,  asparagus,  and  onions — in  these  diseases  will 
at  once  suggest  itself,  I  have  already  spoken  of  gonorrhoea 
as  a  cause  of  cystitis,  and  need  not  dwell  on  it  here. 

Treatment. — Chronic  cystitis  requires  local  as  well  as  con- 
stitutional treatment.  In  this  work,  of  course,  the  constitu- 
tional or  medical  treatment  alone  will  be  given.  The  stereo- 
typed practice — rest,  opium,  and  alkalies — in  cystitis  is  far 
from  meeting  all  requirements.  In  fact,  opium  is  often  inju- 
rious ;  rest,  however,  is  necessary.  The  constitutional  treat- 
ment consists,  first  of  all,  in  so  regulating  the  character  of  the 
urine  that  it  shall  be  unirritating  to  the  diseased  organ.  Pain 
and  vesical  tenesmus  should  be  relieved  if  possible.  The 
skin  should  be  kept  in  a  healthy  and  active  condition,  and 
the  bowels  regular  and  free,  in  order  to  prevent  all  straining 
at  stool  and  secure  unimpeded  action  of  the  portal  circula- 
tion. Free  elimination  by  the  skin  and  bowels  will  give  the 
kidneys  and  bladder  less  to  do.  To  overcome  existing  con- 
stipation, saline  laxatives  should  be  used,  A  glass  of  purga- 
tive mineral  water,  given  an  hour  before  breakfast,  answers 
very  well  in  most  cases.  Cold-water  enemata  are  advised  by 
good  authorities,  but  they  are  not  often  useful. 

Winckel  recommends  the  use  of  saline  laxatives,  pushed 
to  a  point  where  intestinal  hyper^emia  is  produced  and  main- 
tained for  a  time.  He  believes  that  the  blood  in  this  man- 
ner may  be  to  a  certain  extent  diverted  from  the  bladder. 
I  know  from  experience  that  the  practice  is  a  sound  one.  A 
case  of  my  own  is  of  interest  as  showing  the  benefit  effected, 
presumably,  in  this  way. 

A  lady  had  catarrh  of  the  bladder  of  some  months'  stand- 
ing, which  I  had  been  treating  in  the  usual  way  with  only 
slight  benefit.  She  was  one  day  attacked  with  cholera  mor- 
bus accompanied  by  serious  purging  and  vomiting,  the  former 


CYSTITIS.  459 

almost  as  severe  as  that  of  Asiatic  cholera.  The  effect,  for  a 
time,  was  to  almost  suspend  the  action  of  the  kidneys.  When 
she  recovered,  she  was  delighted  to  find  that  her  cystitis  had 
left  her. 

Among  the  conditions  which  produce  irritating  urine,  and 
hence  tend  to  produce  cystitis  or  to  aggravate  it  if  it  already 
exists,  are  indigestion,  malnutrition  from  any  cause,  syphilis, 
and  the  strumous,  gouty,  tuberculous,  and  rheumatic  diath- 
esis. When  any  one  of  these  is  present  it  should  be  treated 
for  the  general  relief  of  the  patient  and  the  indirect  effect 
upon  the  bladder. 

The  diet  of  those  suffering  from  this  disease  must  be  care- 
fully regulated.  The  most  important  of  all  drinks  is  pure 
water.  When  the  urine  is  not  excessively  acid,  I  prefer  dis- 
tilled water,  which  may  be  taken  freely  and  with  good  effect. 
When  an  alkali  is  required,  bicarbonate  of  soda  should  be 
added  to  the  distilled  water.  The  latter  may  be  made  agree- 
able by  slightly  aerating  it.  Milk  will  be  found  to  agree  ex- 
cellently in  most  cases.  In  the  hands  of  Dr.  George  Johnson, 
of  England,  an  exclusive  milk  diet  has  cured  several  cases, 
some  of  great  severity  and  long  standing. 

He  says  :  "The  milk  may  be  taken  cold  or  tepid  and  not 
more  than  a  pint  at  a  time,  lest  a  large  mass  of  curd,  difficult 
of  digestion,  forms  and  collects  in  the  stomach.  Some  adults 
will  take  as  much  as  a  gallon  in  the  twenty-four  hours.  With 
some  persons  the  milk  is  found  to  agree  better  after  it  has 
been  boiled,  and  then  taken  either  cold  or  tepid.  If  the  milk 
be  rich  in  cream,  and  if  the  cream  disagree — causing  heart- 
burn, headache,  diarrhoea,  or  the  symptoms  of  dyspepsia — it 
may  be  partially  removed  by  skimming.  Constipation,  which 
is  one  of  the  most  frequent  and  troublesome  results  of  an  ex- 
clusively milk  diet,  is  to  s(jme  extent  obviated  by  the  cream 
in  the  unskimmed  milk.  When  the  vesical  irritation  and 
catarrh  have  passed  away,  solid  food  may  be  combined  with 
the  milk,  and  a  gradual  return  made  to  the  ordinary  diet." 

I  have  tried  this  method  of  treatment  in  several  in- 
stances with  decided  benefit. 

30 


460  MEDICAL  GYNECOLOGY. 

I  may  briefly  state  that  the  bill  of  fare  usually  given 
consists  largely  of  fluid  foods,  as  milk,  yolk  of  eggs,  soups, 
and  beef  essence.  Lean  meat  in  small  amount  once  a  day, 
and  other  solid  or  semisolid  foods  that  are  easily  digested 
and  nutritious,  may  also  be  allowed.  The  cause,  whatever 
it  may  be,  should  if  possible  be  removed  ;  and  the  remedies 
must  be  adapted  to  the  stage  and  condition  of  the  inflam- 
mation. In  the  acute  stage  aggravated  by  exposure  to  cold, 
diaphoretics  should  be  freely  used,  and  the  patient  made  to 
rest  as  quietly  as  possible.  Diuretics  should  be  given  if  the 
urine  is  loaded  with  solid  material,  and  the  alkaline  salts  are 
to  be  preferred.  Yichy  water  or  flaxseed  tea,  with  citrate  or 
nitrate  of  potash,  will  answer  very  well  at  the  beginning  of 
the  treatment.  In  using  such  salines,  it  serves  admirably  to 
give  them  in  an  infusion  of  buchu  in  case  the  patient's 
stomach  does  not  rebel  at  the  taste  of  it.  This  of  itself  is  a 
most  valuable  remedy  in  almost  all  bladder  affections.  Care 
must  be  taken,  however,  not  to  push  diuretics  too  far.  Suffi- 
cient to  bring  the  urine  to  its  normal  proportions,  and  make 
it  slightly  alkaline  if  naturally  acid,  is  all  that  is  required. 

In  the  early  stages  of  acute  cystitis,  as  well  as  in  irritable 
bladder,  Sidney  Ringer  and  other  authorities  strongly  com- 
mend the  use  of  minim  doses  of  tincture  of  cantharides  re- 
peated every  hour,  and  even  oftener,  but  I  have  not  seen 
very  good  effects  from  its  use  in  cystitis.  To  relieve  pain, 
conium  is  indicated,  and  it  may  be  given  with  ordinary  doses 
of  camphor.  If  there  is  any  objection  to  anodynes  given  in 
this  way,  or  if  there  is  sympathetic  rectal  tenesmus,  supposi- 
tories of  stramonium  and  belladonna  should  be  used. 

While  I  have  said  that  opium  may  be  given  at  the  onset 
of  acute  cases,  and  to  relieve  the  suffering  in  old  cases  that 
can  not  be  cured,  I  must  insist  upon  the  great  harm  that  may 
come  from  the  injudicious  use  of  this  drug  in  cystitis.  It 
deranges  the  digestive  organs  and  the  secretions  generally, 
especially  that  of  the  kidneys  ;  and,  by  changing  the  quanti- 
tative composition  of  the  urine,  renders  it  irritating  to  the 
bladder. 


CYSTITIS.  461 

In  some  cases,  where  frequent  urination  and  tenesmus  are 
very  severe,  owing  to  excessive  nervous  irritability,  twenty- 
grain  doses  of  the  bromide  of  jjotassium,  every  four  hours 
until  relieved,  act  very  nicely  ;  indeed,  this  succeeds  some- 
times where  conium  fails  entirely.  Recently  I  have  used 
hydrobromic  acid,  and  find  that  it  acts  even  better  than  the 
bromide  of  potassium  in  certain  cases. 

Eucalyptus  globulus  is  worthy  of  a  trial  in  obstinate  forms 
of  the  disease.  From  its  well-marked  beneficial  action  in  al- 
buminuria and  other  afl'ections  of  the  urinary  tract.  Dr.  W. 
Anderson  was  led  to  try  it  in  cystitis,  and  he  reports  it  as 
decidedly  useful.  Dr.  J.  J.  Mulheron,  of  Detroit,  gives  it  in 
doses  of  twenty  minims  in  subacute  cystitis  with  good  results. 
As  this  remedy  has  tonic,  antiperiodic,  and  antiseptic  prop- 
erties, it  might  be  especially  suitable  in  malarious  districts. 

Benzoic  acid  is  perhaps  the  drug  that  would  be  found 
most  useful  in  the  largest  number  of  cases.  It  often  seems 
to  act  like  a  specific,  giving  speedy  and  permanent  relief.  It 
may  be  given  in  about  ten-grain  doses,  in  infusion  of  buchu, 
three  or  four  times  a  day.  As  the  acid  is  sparingly  soluble 
in  cold  water,  an  equal  proportion  of  borax  may  be  added  to 
the  mixture.  To  insure  a  perfect  solution,  one  may  prescribe 
the  benzoate  of  ammonia,  which  in  the  same  dose  acts  admi- 
rably and  is  more  palatable. 

In  the  more  advanced  stages  of  the  disease  remedies  are 
used  for  their  direct  effect  upon  the  mucous  membrane,  and 
much  good  is  obtained  in  this  way.  The  drugs  which  have 
the  best  reputation  in  urethritis  are  employed  in  cystitis. 
Balsam  of  Peru  and  of  copaiba,  oil  of  turpentine,  and  tar 
water  are  the  most  important  of  this  class,  and  should  be 
given  in  capsules  in  the  same  way  as  in  gonorrhoea.  Oil  of 
sandalwood  is  also  valuable  in  chronic  cases. 

When  the  pain  is  not  severe,  and  the  urine  is  loaded  with 
mucus  and  pus,  astringents  should  be  given.  Tannin  con- 
tinued for  a  considerable  time  is  of  very  great  value.  Decoc- 
tion of  uva  ursi,  in  half-ounce  doses,  may  also  be  used  for 
this  purpose. 


462  MEDICAL   aYNECOLOGY. 

Dr.  B.  A.  Segur,  of  this  city,  lias  used  salicylate  of  soda 
in  purulent  cystitis,  and  found  that  the  quantity  of  pus  in 
the  urine  rapidly  decreased  under  the  use  of  this  remedy. 
Dr.  Sansom,  of  London,  found  that  the  administration  of 
carbolic  acid  and  the  sulphocarbolates  to  animals  prevented 
the  decomposition  of  urine,  although  he  could  not  detect  any 
of  the  salt  in  the  secretion.  He  gave  the  sulphocarbolates, 
and  afterward  collected  and  preserved  the  urine,  which  after 
six  months  had  not  decomposed.  This  fact  should  be  kept 
in  mind,  and  turned  to  account  in  cases  where  there  is  a  ten- 
dency to  decomposition  from  retention  or  other  causes.  An 
English  physician  reports,  in  the  Canadian  Practitioner,  that 
he  has  met  with  no  case  of  offensive  urine  (intestino-vesical 
fistula  excepted)  that  ten  or  twenty  grains  of  boric  acid,  given 
every  three  hours,  would  not  cure. 

All  these  remedies  may  be  tried  in  cases  that  are  seen 
early ;  but  when  they  fail,  or  when  the  acute  stage  of  the 
trouble  is  long  past  before  advice  is  sought,  then  local  treat- 
ment must  be  employed,  hence  such  cases  should  be  relegated 
to  the  surgeon's  care. 


CHAPTER  XXXVII. 

FFIiTCTIONAL   DISEASES   OF   THE   URETHEA. 

I  KNOW  of  but  one  form  of  affection  which  properly  comes 
under  this  head,  and  that  is  commonly  denominated  neural- 
gia. A  case  will  occasionally  be  met  in  which  there  are  pain 
and  tenderness  of  the  urethra,  with  frequent  desire  to  uri- 
nate, and  pain  in  doing  so.  In  short,  there  is  a  history  of  sub- 
acute urethritis  ;  but,  upon  the  most  careful  examination  that 
can  be  made,  with  all  the  means  at  one's  command,  there  will 
be  failure  to  find  any  lesions  to  account  for  the  symptoms 
present.  To  this  condition  the  name  neuralgia  has  been  ap- 
plied— rather  improperly,  no  doubt.  From  my  own  observa- 
tion of  this  affection,  in  which  there  are  well-marked  symp- 
toms, with  no  apparent  anatomical  lesions,  I  have  been  led 
to  the  conclusion  that  it  is  a  disease  of  the  nerves  of  the  part 
— one  of  the  neuroses,  as  they  are  called.  It  is  quite  possible, 
however,  that  progress  in  the  diagnosis  of  urethral  diseases 
may  yet  enable  diagnosticians  to  find  lesions  other  than  of 
the  nerves  to  account  for  the  symptoms  presented  by  the 
disease  in  question.  But  for  the  present  it  must  be  classed 
among  the  neuroses. 

So  far  as  I  know,  it  is  an  affection  peculiar  to  young 
women.  I  have  only  seen  it  among  young  married  women  of 
marked  nervous  temperament,  and  who  have  not  borne  chil- 
dren. In  some  of  the  cases  observed  it  was  associated  with 
an  irritable  condition  of  the  introitus  vulvse. 

The  symptoms  are  such  as  occur  in  a  great  variety  of 
pathological  conditions,  and  are  therefore  of  little  value  in 
guiding  to  a  correct  idea  of  the  real  trouble  ;  and,  as  there 

463 


464  MEDICAL   GYNECOLOGY. 

are  no  diagnostic  physical  signs  present,  the  diagnosis  mnst 
be  made  by  exclusion.  A  most  thorough  examination  of  the 
urine  is  necessary,  and  the  urethra  and  neighboring  organs 
should  be  carefully  investigated.  Perhaps  the  greatest  lia- 
bility to  error  lies  in  mistaking  this  condition  for  reflex  irrita- 
tion of  the  urethra  and  bladder,  arising  from  ovarian,  uterine, 
or  rectal  disease.  Careful  inquiry  into  the  condition  of  those 
organs  should  therefore  be  made  before  concluding  that  the 
disease  is  of  the  urethra  itself. 

The  affection  is  fortunately  rare  as  well  as  obscure.  I 
shall  therefore  relate  the  history  of  some  cases,  which  will 
give  the  facts  as  they  were  observed  clinically. 

One  was  that  of  a  lady  of  a  highly  nervous  temperament, 
whose  parents  died  of  tuberculosis.  She  was  twenty-six  years 
of  age,  and  had  been  married  three  years.  From  the  time  of 
her  marriage  she  began  to  suffer  from  painful  menstruation 
and  uterine  leucorrhoea,  and  she  attributed  her  trouble  to 
getting  cold  while  driving  in  an  open  carriage  behind  a  fast 
horse.  She  had  an  anteflexion  of  the  uterus  and  cervical 
endometritis,  and  the  right  ovary  was  large,  tender,  and  pro- 
lapsed. Before,  during,  and  after  her  menses  she  had  smart- 
ing and  burning  pain  in  the  urethra,  with  a  feeling  of  spas- 
modic contraction,  which  sometimes  rendered  urination  diflB- 
cult  and  painful.  In  the  interval  between  the  menstrual 
periods  she  had  tenderness  of  the  urethra  and  discomfort  in 
micturition. 

The  urethra  was  repeatedly  examined  throughout  its 
whole  extent  with  the  endoscope,  but  no  disease  could  be 
found — only  tenderness  and  spasmodic  action. 

She  derived  relief  from  suppositories  of  morphine  and 
belladonna,  but  when  last  seen  still  had  attacks  of  the  same 
trouble.  It  was  supposed  at  first  that  the  urethral  trouble 
was  due  to  the  disease  of  the  uterus,  but  the  former  persisted 
after  the  latter  was  relieved. 

Another  case  was  that  of  a  lady,  aged  twenty-nine,  who 
had  been  married  for  seven  years,  but  had  never  been  preg- 
nant.   She  was  of  a  highly  nervous  temperament,  but  her  gen- 


FUNCTIONAL  DISEASES  OP  THE  URETHRA.  465 

eral  health  had  always  been  good.  She  began  to  menstruate 
at  fourteen  years  of  age,  and  continued  to  do  so  regularly 
but  scantily.  For  several  years  she  had  suffered  from  back- 
ache and  slight  uterine  leucorrhoea,  and  coitus  had  always 
been  painful.  She  had  frequent  and  painful  urination.  The 
uterus  was  small — in  fact,  all  the  reproductive  organs  were 
undersized.  There  was  marked  tenderness  of  the  introitus 
vulvee.  The  remains  of  the  hymen  were  very  tender,  and  at 
the  meatus  urinarius  and  on  the  vestibule  there  were  a  num- 
ber of  quite  small  papillomata  (of  the  same  color  as  the  mu- 
cous membrane)  that  were  also  exceedingly  tender.  These 
were  destroyed  by  an  application  of -equal  parts  of  carbolic 
acid  and  tincture  of  iodine,  and  the  leucorrhoea  was  arrested 
by  the  usual  treatment. 

This  relieved  her  of  all  the  symptoms  except  those  of  the 
urinary  organs.  Her  urine  was  examined  repeatedly,  and 
was  found  to  be  normal.  The  urethra  was  also  investigated, 
but  nothing  wrong  was  found  there  except  that  the  papillse 
appeared  to  be  unusually  prominent.  I  learned  that  if  she 
retained  the  urine  for  an  hour  or  two  the  desire  to  urinate 
passed  off,  and  did  not  return  until  the  bladder  was  fully 
distended.  When  she  did  urinate,  the  desire  to  empty  the 
bladder  continued — i.  e.,  she  had  vesical  tenesmus— but  if  she 
indulged  this  feeling  by  passing  the  urine  repeatedly,  this 
tenesmus  continued,  while  if  she  resisted  the  desire,  it  gradu- 
ally subsided.  This  proved  conclusively  that  the  cause  of  the 
frequent  urination  was  the  condition  of  the  urethra. 

Quite  a  variety  of  agents,  which  I  need  not  give  in  detail, 
here,  were  tried  in  this  case.  Suffice  it  to  say  that  she  only 
derived  benefit  from  coating  the  entire  mucous  membrane  of 
the  urethra  with  subnitrate  of  bismuth  once  a  day  for  a  week, 
and  then  applying  equal  parts  of  tincture  of  aconite  and  aque- 
ous extract  of  opium  twice  a  week  for  a  time.  The  bismuth 
was  made  into  an  emulsion  with  water  and  a  little  acacia,  and 
applied  with  the  pipette.  A  steel  sound  was  also  passed  once 
a  week,  and  allowed  to  remain  in  place  for  about  five  minutes. 
This  gave  pain  at  the  time,  but  relief  followed.     During  the 


4,QQ  MEDICAL  GYNECOLOGY. 

local  treatment  she  took  noiirisMng  food,  iron,  and  arsenic. 
She  may  be  said  to  have  recovered  ;  but  overtaxation,  mental 
or  physical,  would  bring  back  the  trouble  in  a  slight  degree 
for  a  short  time. 

I  shall  briefly  treat  of  some  of  the  more  acute  diseases  of 
the  urethra,  which  belong  to  medicine  rather  than  surgery  : 

Inflammation  of  the  TTrethra,  or  Urethritis. — This  is  of  three 
varieties :  a,  acute  ;  b,  chronic  ;  and  c,  gonorrhoeal. 

Acute  urethritis,  though  not  a  very  frequent  disease  among 
women,  is  a  very  distressing  one,  and  often  difficult  to  relieve. 
In  many  cases  it  will  be  found  to  depend  upon  a  specific 
cause — that  is,  gonorrhcea.  It  is  often  difficult  to  tell  a  spe- 
cific or  venereal  urethritis  from  simple  inflammation  of  that 
portion  of  mucous  membrane  without  an  expert  microscopical 
examination  and  finding  the  gonococci.  There  is  a  difference 
in  the  history  when  the  correct  testimony  is  obtained  from 
the  patient.  Simple  urethritis  usually  comes  on  gradually, 
and  is  often  preceded  by  symptoms  of  uterine  or  vesical  dis- 
ease, while  the  gonorrhoeal  variety  comes  on  rather  abruptly, 
and  is  preceded  or  attended  by  acute  vaginitis  and  vulvitis. 
The  chief  symptom  in  both  varieties  is  painful  urination. 
Sharp  scalding  is  produced  by  the  urine  passing  over  the  ten- 
der surface.  There  is  often  a  frequent  desii'e  to  urinate,  but 
not  so  urgent  as  in  cystitis.  In  some  cases  the  urine  is  re- 
tained for  a  long  time,  evidently  from  a  dread  of  the  pain 
caused  in  passing  it. 

In  quite  a  number  of  cases  I  have  noticed  haemorrhage. 
That  the  blood  comes  from  the  urethra  is  known  by  the  fact 
that  it  is  not  intimately  mixed  with  the  urine  ;  and  after  mic- 
turition it  will  ooze  from  the  meatus  urinarius. 

An  examination  of  the  parts  will  show  signs  of  inflamma- 
tion about  the  meatus,  with  or  without  the  same  condition  of 
the  vulva.  Occasionally  there  is  a  discharge  seen  coming 
from  the  urethra,  but  if  the  parts  have  been  recently  bathed 
this  may  not  be  apparent.  Introducing  the  finger  into  the 
vagina  and  pressing  upon  the  urethra  from  above  downward, 
the  discharge  can  be  started,  unless  the  patient  has  mictu- 


FUNCTIONAL  DISEASES  OF  THE  URETHRA.  4(57 

rated  immediately  before.  The  appearance  of  the  discharge 
corresponds  to  that  of  gonorrhoea  in  its  various  stages.  An 
examination  of  it  with  the  microscope  may  reveal  the  pres- 
ence of  the  gonococcus,  and,  if  so,  that  will  determine  the 
nature  of  the  urethritis.  The  absence  of  that  germ  is  not 
positive  proof  that  the  inflammation  is  not  gonorrhceal,  un- 
less frequent  and  skilled  examinations  fail  to  find  it. 

Cystitis,  which  is  liable  to  be  confounded  with  urethritis, 
may  be  excluded  by  letting  urine  flow  for  a  time,  collecting 
the  remainder  for  examination. 

The  treatment  of  acute  urethritis,  whether  specific  or  not, 
may  be  conducted  on  identical  principles,  using  the  same 
constitutional  remedies,  local  baths,  etc.  This  will  suflice  in 
most  cases  of  acute  disease ;  but  when  it  assumes  the  sub- 
acute form  from  the  beginning,  then  the  use  of  injections  be- 
comes necessary,  hence  transferred  to  the  surgeon. 


PAET   III. 

THE  TRANSITION  FROM  MIDDLE  LIFE  TO  OLD  AGE, 
AND   THE  DISEASES   OF   THAT  PERIOD. 

CHAPTER   XXXVIII. 

THE   MENOPAUSE. 

The  menopause  is  introduced  at  the  beginning  of  Part 
III.,  which  is  devoted  to  advanced  life  and  its  diseases,  be- 
cause it  marks  the  dividing  line  between  middle  life  and  the 
beginning  of  old  age. 

The  permanent  suspension  of  the  menstrual  function  is 
known  by  several  names,  such  as  critical  time,  climacteric  or 
climacteria,  turn  of  life,  and  menopause,  the  latter  term  being 
the  most  expressive  and  preferable. 

The  natural  history  of  the  final  cessation  of  menstruation 
varies  so  much  in  different  individuals  that  it  is  difficult  to 
accurately  give  a  typical  account  of  it.  The  time  when  it 
occurs  ranges  from  forty  to  fifty  years  of  age,  the  average  in 
this  country  being  about  forty-five.  The  menopause  coming 
early  or  late  depends  apparently  upon  the  delicacy  or  health 
and  vigor  of  individuals.  There  is  a  popular  idea  that  those 
who  begin  early  should  stop  early,  but,  according  to  my  ob- 
servations, those  who  reach  the  period  of  puberty  betimes 
because  of  good  health  and  strength,  and  who  continue 
healthy,  are  likely  to  maintain  the  menstrual  function  later 
in  life,  providing  that  all  the  sexual  functions  are  normally 
exercised  throughout  middle  life. 

The  question  has  been  raised  as  to  whether  celibates  do 
not  reach  the  menopause  earlier  than  fruitful  women,  but  I 


THE  MENOPAUSE.  469 

have  not  yet  obtained  facts  sufficient  to  answer  this  definitely. 
In  women  of  good  health,  to  whom  the  change  comes  without 
complications,  I  have  observed  that  in  one  class  the  menstrual 
flow  becomes  less  free  and  shorter  in  duration,  then  a  period 
may  be  missed,  to  be  followed  by  a  recurrence  or  two,  and 
then  it  finally  ends.  In  others  the  intermenstrual  period  is 
lengthened  to  five  or  six  weeks,  and  the  fiow  when  it  does 
come  is  free,  often  profuse,  and  lasts  longer  than  usual.  The 
time  from  the  waning  until  the  final  cessation  of  menstrua- 
tion varies  from  six  months  to  two  years  or  longer. 

The  menopause  being  an  event  which  is  natural  to  woman, 
there  is  nothing  in  its  occurrence  which  should  cause  ill 
health.  Still  it  is  attended  by  certain  phenomena  indicating 
special  modifications  of  the  organization  which  disturb  the 
comfort  and  general  activity  of  the  most  healthy  women, 
though  not  to  a  degree  that  can  be  called  ill  health.  Many 
increase  in  flesh,  become  less  inclined  to  mental  and  physical 
activity,  and  show  signs  of  excrementitious  plethora.  There 
is  usually  constipation,  often  due  to  deranged  secretions,  and 
the  nervous  and  vascular  systems  are  more  or  less  disturbed. 
Very  often  functional  heart  trouble,  irregular  action  and  pal- 
pitation of  the  heart,  with  a  feeling  of  impending  danger,  are 
the  common  symptoms.  These  are  frequently  associated  with 
intercostal  neuralgia  of  the  left  side.  Grave  apprehensions 
on  the  part  of  the  patient  are  excited  by  these  symptoms. 

Similar  indications  appear  in  amenorrhoea  in  young  sub- 
jects. This  points  to  the  fact  that  cessation  of  the  menses  has 
a  peculiar  influence  upon  the  innervation  of  the  circulatory 
system.  The  flushings  of  the  face,  "  hot  flashes,"  from  vaso- 
motor derangement,  annoy  them  sometimes  very  much.  Full- 
ness of  the  head  and  occasionally  headache  and  drowsiness 
during  the  day,  and  disturbed  sleep  at  night,  are  frequently 
noticed.  In  other  cases  the  appetite  fails  slightly  and  there 
is  no  gain  in  weight,  perhaps  a  slight  loss  of  flesh.  The  same 
disturbed  circulation  is  generally  present,  but  there  is,  on  the 
other  hand,  increased  nerve  excitability.  Complaint  is  made 
of  restlessness,  and  a  number  of  minor  symptoms,  such  as  im- 


470  MEDICAL  GYKECOLOGY. 

paired  memory  from  lack  of  interest  and  concentration,  are 
observed  and  often  dreaded.  These  are  the  usual  symptoms 
which  attend  the  menopause  in  healthy  women  living  under 
favorable  circumstances. 

Comparing  the  menopause  with  puberty  shows  that  they 
are  almost  exact  opposites,  the  one  being  a  development  of 
structure  and  establishment  of  function,  the  other  a  decay  of 
structure  and  suspension  of  function.  One  marked  difference 
is  noticeable  :  menstruation  is  complete  and  perfect  from  the 
beginning.  Established  after  all  the  structural  conditions  are 
matured,  it  is  maintained  in  full  effect.  The  menopause 
comes  gradually  as  the  decline  of  the  structures  progresses. 

Atrophy  of  the  sexual  organs  from  impaired  nutrition  is 
the  anatomical  change  that  directly  leads  up  to  the  meno- 
pause. The  ovaries,  having  all  along  been  breaking  down  to 
a  certain  extent,  at  each  ovulation  arrive  at  a  condition  of 
senile  atrophy,  and  no  longer  exert  their  full  influence  in 
the  economy.  There  is  not  now  the  demand  for  so  large  a 
blood  supply,  and  the  uterus  shares  in  the  lowered  nutrition. 
The  ovaries  first  arrive  at  the  stage  of  atrophy  through  a 
gradual  breaking  down  of  the  tissues,  which  causes  incompe- 
tence. This,  no  doubt,  is  the  most  important  factor  in  the 
causation  of  the  menopause,  but  it  is  only  one  of  several. 
There  is,  furthermore,  an  atrophy  or  lowered  nutrition  of  the 
spinal  centers  and  organic  nerves,  which  govern  the  sexual 
organs,  at  this  time  of  life,  and  the  brain  also,  to  some  extent, 
withdraws  its  influence  from  them.  Simultaneously  with 
these  changes  the  uterus  becomes  atrophied,  the  degenera- 
tion progressing  slowly.  There  is  at  first  angemia  of  the 
uterus,  which  is  ap]oarent  in  the  pallor  of  the  vaginal  and 
cervical  mucous  membranes.  The  whole  organ  gradually 
diminishes,  until  finally  it  approximates  to  the  infantile  in 
form  and  size,  although  the  senile  uterus  is  a  little  larger 
than  that  of  a  child.  When  these  anatomical  changes  are 
completed  menstruation  ends,  but  the  atrophic  diminution 
continues  for  some  time  after  the  menopause. 

As  already  stated,  the  menopause  occurs  in  consequence 


THE  MENOPAUSE.  47I 

of  a  decline  or  atrophy  of  the  sexual  organs,  nutritive  supply 
and  innervation  ;  hence  there  should  be  a  harmonious  falling 
off  in  all  the  structures  concerned  in  the  functions  of  the  sexual 
organs.  When  that  is  the  case  the  change  of  life  is  free  from 
anything  that  requires  the  attention  of  the  physician  ;  but 
when  the  nutritive  changes  which  precede  the  suspension  of 
the  menstrual  function  progress  faster  in  one  portion  of  the 
economy  than  in  another,  morbid  disturbances  arise.  It  fol- 
lows that  certain  affections  which  occur  at  the  menopause  are 
due  to  deranged  nutrition  and  premature  deterioration  of  that 
portion  of  the  cerebro-spinal  sympathetic  systems  which  gov- 
ern the  sexual  organs.  Others  are  due  to  premature  or  de- 
layed atrophic  or  destructive  changes  in  the  sexual  organs 
themselves. 

Varying  forms  of  derangements  may  arise  from  these 
causes.  For  example:  Withdrawal  of  the  mental  influence 
may  cause  suppression  of  the  menses  before  the  sexual  or- 
gans are  atrophied,  and  an  over-devotion  to  matters  sexual 
may  cause  menstruation  to  continue  in  an  imperfect  way 
after  the  wasting  of  the  uterus  and  ovaries  takes  place  to 
some  extent.  On  the  other  hand,  degeneration  of  the  ova- 
ries and  uterus  may  cause  suppression  of  the  menses  while 
the  cerebro-spinal  structures  may  still  be  perfect  and  func- 
tionally active.  Certain  diseases  of  the  sexual  organs  may 
keep  up  a  modified  form  of  menstruation  after  the  nutrition 
of  the  nervous  system  has  begun  to  decline.  When  this  lat- 
ter condition  prevails,  the  nervous  and  nutritive  systems  have 
a  drain  imposed  upon  them  which  they  are  incapable  of  sus- 
taining, and  consequently  suffer  derangement.  On  the  con- 
trary, while  the  nutritive  and  nervous  systems  remain  healthy 
and  active  there  is  a  necessity  for  menstruation,  and  if  (owing 
to  atrophy  or  malnutrition  of  the  sexual  organs)  menstruation 
is  suspended  the  general  economy  is  sure  to  be  deranged. 

The  derangements  and  disorders  incident  to  the  meno- 
pause may  be  classified,  according  to  the  way  in  which  they 
are  manifested,  under  three  heads  :  premature  or  delayed 
menopause,  and  constitutional  derangements  accompanying 


472  MEDICAL   GYNECOLOGY. 

or  following  the  menopause.  The  latter  is  subdivided  into 
nutritive  and  nervous  disorders  consequent  upon  the  suspen- 
sion or  undue  continuance  of  this  function. 

Premature  Menopause. — The  function  of  menstruation  may- 
be suddenly  suspended,  or  it  may  gradually  subside  and  end 
completely  at  too  early  an  age.  The  abrupt  ending  of  men- 
struation being  the  most  unnatural,  gives  rise  to  the  greater 
disturbance  of  the  general  health.  The  causes  of  premature 
menopause  are  of  two  classes:  diseases  and  injuries  of  the 
sexual  organs,  and  diseases  of  the  nutritive  and  nervous  sys- 
tems. By  recalling  the  conditions  necessary  to  normal  men- 
struation, given  in  the  chapter  on  Menstruation,  it  will  be  seen 
how  these  causes  are  operative.  The  disorders  of  the  sexual 
organs  which  cause  a  premature  menopause  are  degenerative 
disease  of  both  ovaries,  double  ovariotomy,  and  loss  of  the 
uterus  or  injuries  to  it,  which  lead  to  its  premature  atrophy. 
Of  the  latter,  the  most  conspicuous  are  hysterectomy,  the 
ovaries  being  left ;  puerperal  metritis,  which  results  in  super- 
involution  ;  and  extensive  lacerations  followed  by  the  forma- 
tion of  much  scar  tissue.  Operations  for  the  relief  of  deep 
bilateral  lacerations  requiring  removal  of  large  portions  of 
uterine  tissue  may  lead  to  atrophy.  This  has  been  noticed 
by  several  observers  in  late  years. 

Removal  of  the  ovaries  may  be  taken  as  the  principal 
cause  of  abrupt  menopause.  Ovaries  that  are  slowly  de- 
stroyed by  disease  bring  about  the  menopause  more  gradu- 
ally. This  is  made  quite  apparent  from  the  clinical  facts, 
that  those  who  have  well-defined  destructive  diseases  of  the 
ovaries  menstruate  imperfectly  for  some  time,  and  suffer  very 
little  from  the  menopause  when  it  is  completed  by  the  re- 
moval of  the  ovaries  and  tubes,  because  the  change  comes 
more  like  the  natural  way.  Premature  menopause  caused 
abru^Dtly  by  removal  of  functionally  competent  ovaries  and 
tubes,  removal  of  the  uterus,  or  diseases  and  injuries  of  the 
uterus,  which  incapacitate  that  organ  for  performing  its  func- 
tions, give  rise  to  such  marked  derangement  of  the  general 
health  as  to  demand  special  consideration.     Fortunately,  the 


THE   MENOPAUSE.  473 

ovaries  are  not  sacrificed  so  often  now  as  in  the  near  past, 
when  they  were  removed  in  the  vain  hope  of  relieving  certain 
neuroses,  incurable  dysmenorrhoea,  and  uterine  fibromata. 

Symptoms. — The  effect  of  the  removal  of  the  normal  ova- 
ries in  middle  life  is  to  derange  the  nervous,  nutritive,  and 
circulatory  systems.  The  clinical  history  appears  in  many 
cases  to  partake '  of  the  characteristics  of  neurasthenia,  nerv- 
ous irritability,  and  derangement  of  the  emotions.  Great 
muscular  and  nerve  weakness,  indicated  by  continual  weari- 
ness, soon  a-ppears.  In  some  there  is  decided  nervous  irrita- 
bility (that  which  is  known  as  nervousness),  with  a  disposi- 
tion to  try  to  do  much,  but  who  become  easily  fatigued. 
There  is  mental  depression,  indicated  by  sighing  and  lament- 
ing over  real  jDains  and  debility,  and  imaginary  evils  that  are 
present  or  impending.  Much  of  this  depression  and  emo- 
tional disturbance  comes  from  a  consciousness  of  being  sexu- 
ally impotent.  The  nervous  systemic  disturbance  is  mani- 
fested by  headache,  pain  in  the  neck  and  backache,  pain  in 
the  limbs,  tenderness  of  the  skin,  strange  wandering  pains, 
and  queer  feelings  in  the  head  and  elsewhere.  These  symp- 
toms are  the  same  in  kind  as  those  found  in  connection  with 
the  menopause  at  the  right  age  for  it ;  but  in  cases  of  pre- 
mature arrest  of  menstruation  the  disturbances,  mental  and 
physical,  are  greatly  exaggerated. 

Dr.  Savage  (Medical  Press,  November  8, 1893)  calls  attention 
to  some  of  the  mental  troubles  complained  of  by  such  patients. 
They  fancy,  he  says,  that  something  has  burst  in  the  head  or 
womb  ;  have  a  sensation  as  if  hot  blood  were  over  the  brain, 
and  a  feeling  of  deadness  or  emptiness.  With  the  passing 
away  of  the  sexual  functions,  querulousness,  jealousy,  and 
a  fancy  that  their  husbands  no  longer  care  for  them,  not  in- 
frequently occur.  All  of  these  symptoms  I  have  frequently 
observed  in  my  own  practice.  There  are  also  pelvic  tenesmus 
and  pain  in  the  ovarian  regions,  presumably  in  the  stumps 
left  after  the  removal  of  the  ovaries. 

The  next  symptoms  in  the  history  are  derangement  of  the 
circulation,  chiefly  vaso-motor,  due  to  deranged  innervation  ; 


474:  MEDICAL  GYNECOLOGY. 

irregular  heart  action ;  flashes  of  heat,  and  cold  hands  and 
feet ;  cold  perspiration  followed  by  hot,  dry,  feverish  skin  ; 
numbness  of  the  extremities,  most  frequently  of  the  left  arm  ; 
creeping,  crawling  feelings  in  the  skin,  and  burning  spots 
here  and  there.  Nutrition  is  generally  impaired,  and  nerv- 
ous indigestion  is  present  in  all  cases  as  a  rule.  Assimilation 
is  defective,  as  the  loss  of  flesh  and  softened  state  of  the 
muscles  indicate.  The  skin  shows  malnutrition  in  being 
either  dry  and  hot  or  cold  and  clammy.  These  indications 
are  all  more  marked  at  the  time  when  the  patient  should 
menstruate.  These  periodical  exacerbations  are  most  distinct 
at  the  first.  As  time  goes  on  the  patients  adapt  themselves 
to  the  new  order  of  things  gradually.  If  properly  managed, 
recovery  may  take  place  in  time,  but  if  left  without  care, 
they  become  chronic  invalids  or  insane.  Artificial  menopause 
is  more  often  followed  by  insanity  than  the  normal  climac- 
teric. 

The  effect  upon  sexual  instincts  of  removal  of  the  ovaries 
in  adolescence  has  been  discussed  long  and  laboriously  in  the 
past  years,  but  nothing  new  has  been  advanced.  Repetition 
of  the  two  opposite,  old,  and  rather  ridiculous  ideas — one, 
that  the  removal  of  the  ovaries  unsexes  women,  and  the 
other,  that  it  does  not  affect  them  at  all  in  this  respect— is 
about  all  that  has  been  heard  on  this  subject  during  the  last 
eighteen  or  twenty  years.  The  fact  is,  that  it  does  not  unsex 
women,  but  in  time  impairs  sexual  characteristics,  and  they 
are,  as  a  rule,  finally  lost.  The  passing  away  of  the  sexual 
appetence  and  the  consciousness  of  being  positively  sterile 
often  have  a  most  disastrous  effect  upon  the  mind,  and  fre- 
quently lead  to  insanity.  I  will  refer  to  this  again  in  treat- 
ing of  insanity  among  women. 

Treatment. — The  first  indication  is  to  quiet  the  mental 
disturbance.  Much  can  be  done  to  relieve  the  patient's  de- 
pression by  giving  hope  of  recovery.  Sedatives  are  required 
to  give  sleep,  and  nerve  tonics,  such  as  are  suitable  in  melan- 
cholia, are  called  for ;  camphor,  lupulin,  and  in  some  cases 
small  doses  of  opium,  give  relief.    The  opium,  should  be  given 


THE   MENOPAUSE.  475 

with  care,  and  without  the  patient  knowing  what  she  is  tak- 
ing. Lately  I  have  used  codeine  with  better  effect  than  opium 
gives.  The  deranged  circulation  is  best  managed  with  a  com- 
bination of  digitalis,  strychnine,  and  belladonna.  Occasional 
attacks  of  palpitation  of  the  heart — pain  in  the  cardiac  region 
with  difficult  respiration — are  relieved  with  nitroglycerin, 
strophanthus,  and  digitalis.  Indigestion  is  generally  of  the 
nervous  type,  and  is  controlled  by  gastric  sedatives  such  as 
bismuth  and  oxalate  of  cerium,  or  subgallate  of  bismuth.  The 
spinal  symptoms  are,  I  presume,  due  to  a  hypersemic  or  ana- 
bolic state,  hence  the  irritability,  nervous  twitchings,  and 
neuralgic  pains.  When  these  are  annoying,  relief  is  obtained 
by  dry  cupping,  alternating  with  hot  and  cold  douches,  or 
sprayings,  hot  and  cold,  applied  in  rapid  succession  to  the 
lumbar  regions.  Time  is  the  great  factor  in  restoring  the 
equilibrium,  and  the  main  object  is  to  relieve  and  sustain  the 
patient  until  the  new  order  of  things  is  established. 

Enforced  Menopause  from  disease,  injury,  or  removal  of 
the  uterus^  while  the  ovaries  are  left,  causes  a  general  de- 
rangement which  may  be  termed  an  exaggerated  menstrual 
molimen.  The  nutritive  preparations  for  menstruation  go 
on,  and  when  the  eliminative  function  is  not  performed  there 
is  a  temporary  plethora.  The  patient  complains  of  fullness 
of  the  head,  flushed  face,  very  often  headache,  and  oppres- 
sion which  is  felt  as  weakness  and  indisposition  to  engage  in 
mental  or  physical  exercise.  The  nervous  systemic  disturb- 
ance is  manifested  by  drowsiness,  low-spiritedness,  and  in- 
ability to  think  clearly  and  quickly.  Those  of  a  nervous 
temperament  are  irritable,  fretful,  and,  although  sleepy  at 
times  during  the  day,  often  have  sleepless  nights. 

Treatment. — The  old  practitioners  employed  bloodletting, 
and  with  decided  benefit.  In  strong  women  it  might  be 
practiced  with  advantage  at  the  present  time,  but  it  should 
not  be  continued  at  each  recurring  menstrual  period,  as  the 
habit  of  requiring  bleeding  is  easily  established.  Depletion 
by  other  means,  like  saline  cathartics,  for  example,  gives 
much  relief,  and  mercurials  are  of  great  value  when  the  liver 

31 


476  MEDICAL  GYNECOLOGY. 

and  kidneys  are  inactive.  Small  repeated  doses  of  mild 
chloride  of  mercury,  followed  by  a  saline,  or  natural  cathartic 
waters,  act  well,  and  Turkish  baths  and  muscular  exercise 
aid  in  some  cases.  The  headache  often  complained  of  as 
a  painful  fullness  is  best  relieved  by  bromide  of  soda  with 
antipyrine  or  monobromide  of  camphor.  Piperazine  is  the 
best  solvent  and  gives  great  relief  in  the  uric-acid  satu- 
ration which  is  often  present  and  causes  neuralgic,  rheu- 
matic, and  gouty  symptoms.  The  diet  should  consist  of 
milk,  eggs,  vegetables,  and  fruit,  with  very  little  animal 
food.  The  quantity  of  food  should  be  limited ;  underfeed- 
ing rather  than  full  diet  should  be  the  rule.  Some  women 
have  a  craving  for  alcoholic  drinks,  but  these  should  be 
prohibited. 

The  indications  for  treatment  are  based  upon  the  fact  that 
the  function  of  the  sexual  organs  is  suspended  before  the 
nervous  and  nutritive  systems  have  been  prepared  for  the 
change  in  the  economy.  The  nutritive  activities  are  out  of 
proportion  to  the  demand,  and  therefore  the  supply  should 
be  diminished.  If  it  is  not,  the  nutritive  processes  become 
deranged.  These  derangements  should  be  treated  in  the 
usual  way. 

The  disorders  of  the  nervous  system  arising  from  en- 
forced menopause  from  the  causes  now  being  considered  are 
also  twofold.  There  is  in  one  class  an  exalted  nerve  force, 
which,  no  longer  finding  an  outlet  through  the  demands 
of  the  sexual  system,  gives  rise  to  nervous  derangements 
which  should  be  relieved  by  sedatives,  and  diversion  of  the 
nerve  forces  in  some  other  direction  by  mental  occupation. 
Women  who  have  given  their  best  mental  energies  to  the 
exercise  of  the  sexual  system  suffer  most  from  premature 
menopause. 

There  is  another  class  who  suffer  from  nervous  exhaustion 
or  debility.  They  manifest  nervous  excitability  with  loss  of 
power ;  they  are  called  nervous  patients.  All  such  require 
rest,  tonics,  and  good  nourishment.  Whenever  the  nervous 
system  is  specially  disturbed  at  the  menopause  the  greatest 


THE   MENOPAUSE.  477 

care  is  required  to  keep  its  disorders  from  going  from  bad 
to  worse.  Tliere  is  a  tendency  to  develop  diseases  of  the 
nervous  system  in  many  forms,  and  if  there  is  any  inher- 
ited tendency  to  insanity  it  will  be  brought  out  under  these 
circumstances. 

Delayed  Menopause. — The  menstrual  function  is  sometimes 
continued  to  an  advanced  age  in  strong,  healthy  women, 
but  so  long  as  the  function  is  normal  there  is  no  reason  for 
being  alarmed.  It  is  only  when  the  menses  continue  beyond 
the  usual  time  for  the  menopause  and  there  is  some  derange- 
ment in  that  function,  or  the  general  health  is  impaired, 
that  attention  should  be  given  to  the  subject.  Efforts  should 
be  made  to  discover  the  local  or  general  conditions  which 
cause  these  derangements.  When  the  flow  is  profuse  and 
irregular  in  recurrence,  there  is  usually  some  local  cause  for 
it  that  can  be  easily  discovered. 

It  may  be  said  in  brief  that  any  neoplasm,  subinvolution, 
or  old  injuries  of  the  uterus  may  keep  up  menstruation  be- 
yond its  normal  limit.  Scar  tissue  in  the  cervix  uteri,  either 
from  injuries  or  from  the  use  of  caustics,  apparently  prevents 
the  final  atrophy  of  the  uterus  by  keeping  up  a  continuous 
irritation.  This  is  the  only  way  that  one  can  account  for 
the  relief  obtained  in  such  cases  by  dilating  the  canal  of  the 
cervix.  A  number  of  cases  of  recovery  from  painful  men- 
struation and  delayed  menopause  have  been  reported  cured 
by  this  form  of  treatment.  Uterine  fibroids  and  subinvolu- 
tion, as  well  as  scar  tissue  of  the  uterus,  all  belong  to  the 
domain  of  surgery,  and  are  only  referred  to  here  as  belong- 
ing to  causation. 

Delayed  menopause  is  also  caused  by  certain  constitu- 
tional conditions,  such  as  hepatic,  cardiac,  and  renal  disease, 
and  also  certain  blood  states  which,  if  they  do  not  favor  a 
continuation  of  menstruation  long  after  the  time  for  change 
of  life,  certainly  cause  menorrhagia  about  the  time  for  the 
menopause.  Menorrhagia  and  delayed  menopause  are  not 
infrequent  in  cases  of  mitral  insufficiency.  The  effect  of 
this  cardiac  lesion  upon   the  circulation  is   to  keep  up  a 


478  MEDICAL  aYNECOLOGY. 

continued  hypersemia  of  the  pelvic  organs,  and  tMs  often 
causes  women  to  go  on  menstruating  when  they  are  old 
enough  to  have  the  menopause  and  when  they  can  ill  afford 
to  keep  up  that  function.  The  diagnosis  is  easily  made 
by  the  physician  who  makes  his  examination  sufficiently 
thorough. 

The  treatment  consists  in  trying  to  improve  the  circula- 
tion. At  the  menstrual  period  the  patient  should  be  kept  in 
the  recumbent  XDOsition  as  long  as  it  can  be  borne  with  com- 
fort. She  should  rest,  not  necessarily  upon  her  back,  but 
on  either  side  that  is  most  comfortable.  Massage  and  hot- 
water  douches,  which  I  do  not  hesitate  to  recommend,  if  the 
flow  is  excessive,  will  sometimes  control  this  condition. 
Digitalis  and  aromatic  sulphuric  acid  in  medium  doses  will 
frequently  give  great  relief,  and  they  are  far  better  borne 
than  hydrastis  canadensis  or  ergot  in  those  cases  of  cardiac 
disease. 

Hepatic  disease,  such  as  the  engorgement  and  enlarge- 
ment occurring  in  chronic  malarial  poisoning,  not  rarely 
causes  menorrhagia  in  young  women,  and  is  very  apt  to  de- 
lay the  menopause.  This  no  doubt  is  also  due  to  the  de- 
ranged portal  circulation,  which  keeps  up  the  pelvic  engorge- 
ment. The  treatment,  of  course,  should  be  such  as  the  phy- 
sician employs  in  chronic  malaria.  It  will  suflice  to  add  here 
that,  in  addition  to  the  use  of  the  alkaloids  of  cinchona  bark 
and  arsenic,  I  have  found  the  most  marked  benefit  from  the 
use  of  iodine.  I  give  five  drops  of  the  tincture  in  water, 
with  enough  of  the  iodide  of  soda  to  make  a  clear  solution. 
The  formula  is  :  Tincture  of  iodine,  two  drachms  ;  iodide  of 
sodium,  half  a  drachm  ;  simple  sirup,  one  ounce  ;  water,  two 
ounces.  Dose,  one  drachm  after  meals,  well  diluted.  To 
this  I  very  often  add  two  or  three  drops  of  Fowler's  solu- 
tion. Of  course,  attention  to  the  bowels  and  general  nutri- 
tion should  be  fully  given. 

The  premature  menopause  has  been  referred  to  as  arising 
from  certain  constitutional  affections,  notably  tuberculosis 
and  so  on.     Nothing  need  be  said  about  this  here,  as  sup- 


THE  MENOPAUSE.  479 

pression  of  menstruation  is  a  conservative  matter  and  re- 
quires no  direct  attention.  It  may  be  well  to  add  also 
that  in  case  the  physician  can  not  iind  any  disturbance  of 
the  nutritive  or  nervous  system  to  account  for  the  delayed 
menopause,  it  is  evidence  that  the  cause  is  local,  and  such 
patients,  of  course,  should  be  relegated  to  the  domain  of 
surgery. 


CHAPTER   XXXIX. 

DISEASES   OF   OLD   AGE. 

WoMET^  are  longer-lived  than  men,  and  are  more  tenacious 
of  life,  but  they  are  greater  sufferers  in  early  and  middle  life 
than  men.  There  does  not  appear  to  be  any  difference  in 
favor  of  either  sex  in  old  age,  neither  is  there  much  varia- 
tion in  the  nature  of  the  diseases  to  which  they  are  subject. 
Certain  general  changes  of  structure  and  function  and  a  ten- 
dency to  particular  affections  occur  about  equally  in  old  men 
and  women,  but  there  are  various  modifications  of  the  dis- 
eases of  old  age  arising  from  sex  and  some  disorders  peculiar 
to  old  women  which  call  for  special  consideration. 

The  external  appearances  of  old  age  are  the  dry  and 
wrinkled  skin,  white  hair,  stooping  form,  want  of  teeth, 
changes  in  the  shape  of  the  maxillary  bones  which  follow 
the  loss  of  teeth,  and  the  consequent  alterations  in  the  linea- 
ments of  the  face.  There  is  a  diminution  in  height  and  loss 
of  weight,  and  functional  activity  declines  as  the  structures 
decay.  "The  pace  of  age  is  timid  and  cautious — the  foot 
leaves  the  earth  slowly  and  is  planted  down  upon  it  with 
hesitation.  It  is  the  hasty  and  determined  step  of  youth  that 
I  hear  now. "  *  These  changes  are  brought  about  by  a  general 
atrophy  of  the  body.  This  emaciation  varies  in  degree  in 
different  individuals.  In  some  the  accumulation  of  fat  con- 
tinues late  in  life,  but  this  is  exceptional.  The  emaciation 
is  the  consequence  of  a  process  which  produces  atrophy  of 
all  the  tissues  of  the  body — an  atrophy  characterized  by  their 

*  Blind  Alice  in  The  Bride  of  Lammermoor. 


DISEASES  OP  OLD  AGE.  481 

diminution,  without  cliange  of  structure.  Evidently  tissue 
waste  outruns  assimilation  and  restoration. 

There  is  an  exception  of  great  interest  in  the  heart  and 
kidneys,  as  these  organs  maintain  the  dimensions  of  middle 
life.  In  many  old  people  the  heart  becomes  truly  hypertro- 
phi«d.  The  physiological  reason  for  this  preservation  of  the 
dimensions  of  the  heart  and  kidneys  during  old  age  is  not 
fully  agreed  upon  by  authorities. 

I  believe  that  the  heart  preserves  its  size  or  becomes  en- 
larged in  advanced  life  because  it  has  relatively  more  to  do. 
The  blood-vessels  degenerate,  especially  the  capillaries,  and 
the  heart  has  additional  labor  in  order  to  keep  up  the  cir- 
culation. 

The  condition  of  the  heart  may  be  accounted  for  on  these 
grounds,  but  there  is  no  satisfactory  explanation  of  the  kid- 
neys being  an  exception  to  the  rule  of  decay.  They  may  have, 
however,  more  to  do  in  advanced  life,  owing  to  the  fact  that 
digestion  is  imperfect  and  the  liver  and  bowels  less  active. 
Theoretically,  this  would  explain  the  preservation  of  the  size 
of  the  kidneys,  but  there  are  not  sufficient  facts  regarding  the 
function  of  the  kidneys  in  old  age  to  settle  this  question. 

As  age  advances  there  comes,  in  addition  to  the  loss  of 
tissue,  a  change  in  structure  produced  by  degenerative  action. 
The  elements  undergo  a  modification  in  constitution  and  be- 
come the  seat  of  pigmentary,  fatty,  and  calcareous  degenera- 
tion. The  fasciculi  of  the  muscles  of  animal  life  are  changed 
by  deposits  of  fatty  granulations.  This  is  especially  noticed 
in  the  muscles  of  the  legs,  where  it  may  advance  so  far  as 
to  produce  paraplegia  more  or  less  complete.  The  same 
changes  take  place  in  the  muscles  of  organic  life.  The  heart, 
though  slow  to  give  way,  does  not  escape  in  the  long  run,  as 
has  been  often  demonstrated  in  women  who  die  at  an  ad- 
vanced age.  This  degeneration  of  the  cardiac  tissue  gives 
rise  to  asystolism,  often  manifested  in  aged  persons  who 
appear  to  be  in  good  health. 

The  blood-vessels  undergo  degeneration,  especially  the 
cerebral  arteries. 


482  MEDICAL   GYNECOLOGY. 

The  first  deviation  from  tlie  normal  state  of  the  tissues 
appears  like  a  hypertrophy  of  the  inner  coats  of  the  vessels. 
In  time  this  undergoes  fatty  degeneration.  In  the  first  change 
there  is  narro-v\ing  of  the  caliber  of  the  vessels  ;  later  on  they 
become  closed,  the  circulation  is  cut  off  from  the  tissues  de- 
pendent upon  the  arteries  involved,  and  softening  or  gangrene 
results.  Sometimes  the  tissue  breaks  down  into  the  vessels, 
and  small  portions  being  swept  along  with  the  blood  current 
into  smaller  vessels,  cause  cerebral  embolism. 

The  changes  noticed  in  the  structure  of  the  brain  are  first 
an  apparent  predominance  of  neuroglia  over  the  nerve  ele- 
ments, and  then  an  infiltration  of  amyloid  granulations. 
According  to  Bibra,  the  brain  tissue  undergoes  certain  chem- 
ical changes.  There  is  a  diminution  in  the  fatty  material, 
and  an  increase  in  the  proportion  of  water  and  phosphorus. 
Alterations  in  function  accompany  these  changes  of  struc- 
ture. The  appetite  is  lessened,  but  though  in  exceptional 
cases  it  remains  unimpaired,  and  large  quantities  of  food  are 
taken,  the  digestion  is  labored  and  imperfect.  The  dyspep- 
sia of  old  people  is  well  known  to  exist,  and  is  due,  in  part 
at  least,  to  diminution  of  the  gastro-intestinal  secretions.  All 
the  secretions  are  diminished,  that  of  the  skin  and  kidneys 
especially  so.  The  function  of  respiration  is  modified,  owing 
to  the  diminished  capacity  of  the  lungs.  Respirations  are 
increased  in  frequency,  and  the  quantity  of  carbonic-acid 
gas  exhaled  is  diminished.  For  a  long  time  it  was  supposed 
that,  as  digestion  declined  in  activity,  the  temperature  was 
lowered,  and  that  belief  was  apparently  confirmed  by  the 
fact  that  the  surface  temperature  is  lower  in  the  aged.  The 
internal  temperature,  however,  as  taken  in  the  rectum,  is 
about  the  same. 

The  essential  facts  in  this  matter  are,  that  there  is  a  gen- 
eral atrophic  decay  of  all  the  tissues  and  organs  of  the  body, 
and  consequent  impairment  of  function  ;  but,  though  strange, 
it  is  true  that  the  organs  of  the  aged  perform  their  function 
with  an  energy  that  is  sometimes  the  equal  of  that  which 
obtains  in  middle  life. 


DISEASES  OP   OLD   AGE.  483 

Along  with  these  changes  of  structure  and  function  in  the 
general  organization  a  corresponding  decline  is  observed  in 
the  nervous  system  and  mental  faculties.  All  the  senses 
gradually  become  impaired.  First,  the  eyesight  loses  in  its 
powers  of  adjustment,  the  hearing  becomes  less  acute,  al- 
though there  may  be  no  marked  deafness,  the  sense  of  touch 
is  less  keen,  and  taste  and  smell  are  impaired.  The  mental 
faculties  undergo  certain  changes  which  modify  the  personal 
characteristics,  and  there  is  a  gradual  decline  in  the  activity 
and  power  bt  the  mind,  corresponding  in  some  degree  to  the 
noticeable  physical  changes  common  to  old  age.  The  blunted 
senses  make  the  perceptive  faculties  less  active  and  accu- 
rate. The  memory  fails  perceptibly,  and  the  mind  does  not 
take  clear  and  lasting  impressions  as  in  earlier  years.  The 
aged  remember  past  events,  but  forget  the  things  of  to-day. 

The  higher  mental  powers  are  the  last  to  give  way  in  those 
of  cultivated  minds.  The  old,  like  the  very  young,  are  emo- 
tional, and  joy  and  sorrow  come  and  go  quickly.  They  are 
less  susceptible  to  profound  sorrow  from  bereavement,  and 
in  this  they  become  childlike.  The  moral  principle  declines 
with  all  the  rest,  or  at  least  the  mind  is  unable  to  determine 
certain  ethical  distinctions  to  the  extent  it  formerly  was. 
Body  and  mind  decline  gradually,  slowly,  at  about  the  same 
pace  as  they  were  developed.  The  processes  are  alike  in 
many  ways,  though  absolutely  opposite  in  action,  the  one 
leading  up  and  the  other  down.  The  term  ''second  child- 
hood,'' employed  to  define  old  age,  is  very  descriptive  of  the 
state  from  which  the  mature  individual  is  developed  and 
to  which  the  old  return.  Prof.  William  Osier  says,  "Touch 
with  the  slow  finger  of  Time  the  nutrition  of  that  thin  layer, 
and  backward  by  slow  degrees  creep  the  intellectual  facul- 
ties, back  to  childish  simplicity,  back  to  infantile  silliness, 
back  to  the  oblivion  of  the  womb." 

The  sexual  organs  in  women  undergo  complete  atrophy, 
become  rudimentary  in  appearance,  and  their  functions  are 
set  at  rest  for  all  time.  The  mental  characteristics  of  sex  are 
modified  in  the  women  who  grow  old  gracefully.     The  love 


484  MEDICAL  GYNECOLOGY. 

of  children  is  slow  to  decline,  and  the  friendly  affection  re- 
mains. In  fact,  social  life  is  enjoyed  keenly  by  aged  women, 
but  the  sexual  desires  gradually  fade.  The  purely  sexual 
characteristics  are  lost  earlier  in  the  life  of  women  than  of 
men.  In  both  sexes  the  love  of  active  sexual  life  may  con- 
tinue after  the  senile  impairment  has  well  advanced,  but  it 
is  most  so  in  those  who  have  been  given  to  overindulgence 
in  middle  life.  Perverted  abnormal  sexual  excitation  in  aged 
women  is  mostly  a  derangement  of  the  mental  functions. 
Prurient  thoughts  and  actions  are  inspired  by  the  memory 
of  the  past  life  rather  than  by  physical  events  of  the  present, 
or  the  ability  to  gratify  abnormal  wishes. 

Modifications  of  Disease  in  Old  Age. — Age  exempts  from  cer- 
tain diseases,  and  those  that  occur  at  all  ages  are  modified 
when  they  happen  in  advanced  life.  Though  old  age  pre- 
disposes to  certain  affections,  there  are  various  immunities 
created  by  it.  The  eruptive  and  essential  fevers  and  phthises 
are  rare  at  the  latter  period  of  life.  The  functional  affections 
of  the  nervous  system,  like  hysteria  and  neurasthenia,  so 
common  in  early  life,  are  seldom  seen  in  the  aged.  Perhaps 
the  most  important  modification  is  in  the  subjective  symp- 
toms of  disease  being  less  defined  in  the  aged.  Pneumonia, 
for  example,  which  is  common  in  advanced  life,  is  in  many 
cases  far  advanced  before  there  is  any  complaint  of  suffering 
made  by  the  patient.  This  may  be  accounted  for  by  the 
feelings  being  blunted.  Vaginitis  and  displacements  of  the 
vagina,  rectum,  and  bladder  are  often  found  in  old  women, 
who  do  not  manifest  as  much  discomfort  therefrom  as  their 
younger  sisters. 

The  diseases  of  old  age  which  are  directly  related  to  sex 
are  quite  limited,  but  there  are  a  number  of  affections  that 
are  influenced  by  sexual  characteristics,  and  I  propose  to  dis- 
cuss some  of  the  most  important  of  them. 

Dyspepsia  and  constipation  are  in  the  main  alike  in  both 
sexes,  but  there  are  some  peculiarities  in  women  which  should 
be  noticed.  Indigestion  caused  by  imperfect  secretion  and 
gastric  catarrh  are  fully  given  in  works  on  general  practice, 


DISEASES  OF  OLD  AGE.  485 

and  so  also  are  other  intestinal  diseases  and  derangements  ; 
but  something  should  be  said  in  this  connection  about  di- 
arrhoea  and  constipation  in  aged  women.  These  opposite 
conditions  are  caused  by  changed  or  deficient  secretion  in 
most  cases.  In  women  the  constipation  is  often  to  a  great 
extent  due  to  atrophy  of  the  muscular  coat  of  the  intestines, 
especially  of  the  rectum.  This  is  manifested  by  the  sac- 
culated state  of  the  latter,  often  found  in  aged  patients. 
Haemorrhoids  and  prolapsus  of  the  rectum  often  follow  as 
results  of  tlie  muscular  atrophy  ;  fecal  impaction  occasional- 
ly occurs,  and  frequently  there  is  much  trouble  experienced 
in  emptying  it  when  the  bowels  are  free  enough.  The  inabil- 
ity to  evacuate  the  rectum  may  be  caused  in  several  ways. 
The  muscular  atrophy  incident  to  old  age,  and  distention 
from  constipation,  produce  a  sacculated  condition  of  the  part 
and  loss  of  muscular  power  to  expel  its  contents.  In  other 
cases  the  rectum,  though  weak,  is  all  right,  but  the  sphincter 
muscle  is  irritable  and  resists  the  feeble  efforts  of  the  rectum 
to  overcome  its  contraction.  There  is  still  another  condition 
which  causes  difficulty  of  evacuation,  and  that  is  sagging  of 
the  pelvic  floor.  In  that  state,  contraction  of  the  rectum  and 
voluntary  efforts  only  push  the  pelvic  floor  down,  but  do  not 
dilate  the  sphincter. 

The  sacculated  rectum  is  relieved  by  daily  washing  it  out 
with  an  enema  and  using  an  astringent,  like  tannin  or  zinc  in 
solution.  The  tonic  contraction  of  the  sphincter  is  overcome 
by  the  use  of  the  dilator  or  stretching  to  a  limited  degree. 
In  the  sagging  of  the  pelvic  floor  the  patient  or  nurse  should 
support  the  perinaeum  while  efforts  are  made  to  have  an 
evacuation.  Varicose  veins  in  the  pelvic  floor  and  around 
the  lower  margin  of  the  rectum  often  appear,  and  the  vagina 
also  becoming  involved,  especially  the  posterior  wall,  there  is 
prolapse  of  one  or  both  walls.  All  these  pathological  changes 
occur  more  certainly  in  those  who  have  sustained  injuries  of 
the  pelvic  floor  in  middle  life. 

Malnutrition  of  the  integument  of  the  pelvic  floor,  vulva, 
and  anus  generally  accompanies  the  changes  noticed  above, 


486  MEDICAL  GYNECOLOGY. 

and  is  one  of  the  causes  of  pruritus,  that  most  distress- 
ing affection.  Sometimes  the  irritation  is  due  to  eczema,  in 
others  there  is  no  ajDparent  cause  for  it.  Some  degenerative 
change  in  the  terminal  nerve  fibers  probably  produces  the 
troublesome  symptom  not  otherwise  accounted  for.  The  mu- 
cous membrane  undergoes  fatty  degeneration  and  leads  to 
ulceration  of  the  hsemorrhoidal  tumors  and  occasionally 
painful  fissures  between  the  haemorrhoids.  These  conditions 
are  spoken  of  by  patients  as  painful  and  'bleeding  piles. 

Causation. — The  predisposing  cause  of  these  pathological 
changes  in  the  rectum  is  the  general  senile  atrophy.  Seden- 
tary habits  and  constipation,  so  common  among  aged  women, 
carry  the  wasting  of  old  age  beyond  the  usual  limit  and 
aid  in  bringing  about  the  various  lesions  now  under  con- 
sideration. Lacerations  of  the  pelvic  floor  which  have  been 
left  unrepaired  are  also  operative  in  the  causation.  Such 
injuries,  however,  are  not  by  any  means  the  chief  cause  of 
these  affections  of  the  rectum,  nor  of  prolapsus  of  the  vagina 
and  bladder  which  frequently  occur  at  the  same  time  of  life. 
All  these  lesions  have  been  repeatedly  found  in  those  who 
have  never  sustained  any  form  of  injury. 

Treatment. — It  is  far  more  easy  to  prevent  diseases  of  the 
rectum  than  to  cure  them,  especially  if  they  are  far  advanced 
before  relief  is  sought.  All  injuries  of  the  pelvic  floor  should 
be  operated  upon,  even  when  they  have  not  been  discovered 
until  the  menopause  or  soon  after.  Patients  are  disposed  to 
decline  having  surgical  treatment  at  the  end  of  active  func- 
tional life,  claiming  that  they  do  not  suffer  much  if  any  incon- 
venience, and  they  fear  that  they  are  too  old  to  really  need 
surgical  treatment.  The  unwise  physician  may  take  a  simi- 
lar view  of  the  matter.  The  judicious  surgeon  will  point 
out  to  such  patients  that  the  treatment  proposed  is  not  alone 
for  present  relief,  but  for  protection  in  the  future,  and  for 
that  very  good  reason  surgical  treatment  should  be  employed. 
Constipation  should  be  prevented  by  laxatives  and  attention 
to  diet. 

It  is  not  an  easy  matter  to  find  a  suitable  laxative  for 


DISEASES  OP   OLD   AGE.  487 

aged  women.  In  old  age,  as  at  all  periods  of  life,  it  is  found 
that  the  thing  that  will  agree  with  one  will  not  do  for  an- 
other. As  a  rule,  tonic  laxatives  are  most  suitable  for  the 
aged,  salines  rarely  so  in  very  old  cases.  The  secretions,  if 
defective,  should  be  stimulated  by  small  but  often-repeated 
doses  of  rhubarb  and  belladonna,  with  nux  vomica  or  cascara 
elixir.  Aloin  and  belladonna  answer  well  in  some  cases. 
The  rules  to  be  observed  in  the  use  of  laxatives  is  small 
doses  often  repeated.  This  is  a  good  rule  for  guidance  at  all 
times,  but  it  applies  with  especial  force  in  advanced  life. 

In  case  the  rectum  is  atrophied  and  the  sphincter  strong, 
great  help  will  be  found  in  the  use  of  the  rectal  dilator,  as 
already  stated. 

Haemorrhoids  should  be  treated  medicinally,  in  the  very 
aged  at  least.  I  have  had  gratifying  results  from  using  the 
following  suppository :  Iodoform,  sixty  grains  ;  balsam  of 
Peru,  thirty  grains  ;  extract  of  ergot,  twenty  grains  ;  and  two 
grains  of  extract  of  belladonna,  made  into  twelve  supposito- 
ries, one  to  be  used  at  bedtime.  In  the  morning,  after  the 
bowels  are  moved,  one  or  two  drachms  of  the  following  mix- 
ture are  instilled  into  the  rectum  :  Sulphate  of  zinc,  six 
grains  ;  fluid  extract  of  hydrastis  canadensis  and  water,  each 
an  ounce.  This  course  of  treatment  is  of  much  value  in 
ulceration  and  fissures  of  the  rectum.  I  usually  begin  the 
treatment  of  fissures  by  making  an  application  of  cocaine, 
followed  with  one  part  of  tincture  of  iodine  and  two  of  car- 
bolic acid.  In  those  who  are  not  very  old  and  feeble  the 
sphincter  should  be  moderately  dilated  before  the  applica- 
tion is  made. 

In  a  few  there  is  a  dermatitis  about  the  anus  and  much 
nervous  irritation.  Borax  and  water  bath,  glycerin  applica- 
tions, and  cocaine  lotion  or  ointment  usually  give  relief. 

DiarrTicea  in  tJie  Aged  Woman. — The  pathology  of  this 
affection  is  to  some  extent  different  from  that  found  in  early 
and  middle  life.  In  the  aged  there  are  degeneration  of  the 
mucous  membrane  and  irritability  ;  and  digestion  being  less 
perfect,  the  contents  of  the  alimentary  canal  cause  disturb- 


488  MEDICAL  GYNECOLOGY. 

ance  and  diarrhoea.  Errors  in  diet  and  changes  of  tempera- 
ture are  more  certain  to  cause  diarrhoea  in  the  aged  than  in 
younger  subjects.  Fatigue  may  also  bring  on  relaxation  of 
the  bowels.  Septic  material  and  depraved  secretions  may 
cause  diarrhoea  in  advanced  life,  but  the  ordinary  bov^el 
troubles  of  old  women  are  generally  due  to  the  causes  first 
named. 

In  the  treatment,  sedatives  and  astringents  give  the  best 
results  in  the  majority  of  cases.  The  antiseptic  treatment 
of  intestinal  disorders  introduced  in  recent  years  is  seldom 
applicable  in  advanced  life.  Bismuth  and  tannin  with  opium 
usually  give  relief. 


CHAPTER  XL. 

SENILE  EIS^DOMETRITIS. 

There  is  a  decided  immunity  of  the  uterus  from  inflam- 
matory disorders  in  aged  women,  and  that  fact  has  given  rise 
to  the  prevailing  opinion  that  cancer  is  the  only  disease  of 
the  uterus  to  be  looked  for  after  the  menopause.  In  the  past 
and  at  present,  authorities  have  agreed  in  stating  that  endo- 
metritis ends  in  recovery  at  the  change  of  life.  These  opin- 
ions are  true  only  to  a  certain  extent.  I  have  seen  a  number 
of  cases  of  endometritis  which  persisted,  in  a  modified  form, 
after  the  menopause,  and  a  considerable  number  in  which 
this  trouble  appeared  long  after  the  climacteric.  The  path- 
ology and  natural  history  of  endometritis  in  advanced  life 
differ  so  from  inflammatory  affections  of  the  uterus  in  mid- 
dle life  that  I  concluded  eighteen  or  twenty  years  ago  that 
senile  endometritis  was  a  special  disease  worthy  of  more  at- 
tention than  had  been  given  to  it.  Fritsch,  in  Billroth's 
Handbuch  fiir  Frauenkrankheiten,  treats  of  this  affection, 
and  three  or  four  others  have  referred  to  his  contributions, 
and  that  is  all  I  can  find  in  the  literature  of  it.  Even  at  the 
present  time  there  are  only  four  or  five  authors  who  make 
any  allusion  to  it. 

The  subject  was  first  brought  to  my  notice  most  forcibly 
in  the  year  1875.  A  patient,  the  relative  of  a  physician,  aged 
sixty-eight,  came  under  my  care  while  suffering  from  a  sero- 
purulent  discharge  from  the  uterus.  I  made  a  diagnosis  of 
cancer,  but  found  I  was  mistaken.  She  recovered,  but  I 
could  see  that  this  affection  differed  from  endometritis  as 
it  occurs  in  middle  life.     From  that  time  I  have  kept  such 


490  MEDICAL  GYNECOLOGY. 

cases  carefully  under  observation,  and  collected  facts  suj93l- 
cient  to  complete  the  natural  history  of  the  disease. 

Pathology. — The  inflammation  may  be  limited  to  the 
cervix  alone,  bnt  as  a  rule  it  involves  the  entire  mucosa. 
When  it  occurs  soon  after  the  menopause,  and  especially  if 
it  is  a  continuation  of  a  cervical  endometritis  that  existed  be- 
fore the  menstrual  function  was  finally  suspended,  it  assumes 
a  modified  form.  As  usually  seen,  it  is  suppurative,  the  dis- 
charge being  sero-purulent.  When  it  begins  as  a  catarrh  it 
gradually  progresses  to  a  suppurative  form.  In  the  catarrhal 
form,  the  discharge,  at  first  a  leucorrhoea,  diminishes  and 
changes  from  a  translucent  tenacious  material  to  a  darker, 
gluelike  one,  associated  with  a  sero-purulent  matter.  The 
change  results  from  the  atrophy  of  the  glands  of  JS'aboth 
which  secrete  the  leucorrhoeal  discharge  of  catarrhal  endo- 
metritis. The  character  of  the  discharge  is  modified  first  by 
the  atrophy  which  follows  the  menopause  and  by  changes 
of  structure  which  are  produced  by  the  disease  itself.  It  is 
not  until  the  senile  involution  is  complete  that  the  patho- 
logical anatomy  of  the  disease  is  fully  developed  and  shows 
the  characteristics  which  distinguish  this  affection  from  all 
other  forms  of  endometritis. 

There  is  first  a  general  atrophic  thinning  of  the  whole 
mucous  membrane.  The  epithelium  changes  from  ciliated  to 
cylindrical,  then  pavement,  and  finally  is  almost  entirely  lost. 
The  surface  around  the  os  externum  becomes  irregular,  thin, 
and  shows  a  bluish-red  color,  which  presents  a  marked  con- 
trast to  the  appearance  of  erosion  seen  in  endometritis  of 
early  life.  Gfranulations  of  low  vitality  appear  on  the  en- 
dometrium, and  minute  extravasations  of  blood  occur  and 
are  seen  as  small  pigmentation  spots.  The  glands  become  ob- 
literated entirely  by  the  morbid  process,  and  hence  there  can 
be  no  secretion,  but,  instead,  pus  formation.  There  is  molecu- 
lar death  of  the  structures,  but  extensive  ulceration  is  rare. 

During  the  development  of  this  affection  the  atrophy  of 
the  muscular  structure  of  the  cervix  proceeds  faster  than  in 
the  mucous  membrane  of  the  cervix,  and  there  is  an  inver- 


SENILE  ENDOMETRITIS.  491 

sion  of  the  membrane  which  gives  a  peculiar  appearance. 
Around  the  os  externum  there  is  an  elevated  bluish-red  ring 
which  stands  out  beyond  the  rest  of  the  cervix.  Laceration 
of  the  cervix  uteri  frequently  accompanies  senile  inflamma- 
tion, and  when  there  is  much  scar  tissue  present  the  suffer- 
ing is  more  marked.  Stricture,  partial  or  complete,  at  the  os 
internum  or  externum  is  frequently  formed.  Closure  of  the 
OS  internum  is  caused  in  some  cases  by  retroflexion  of  the 
uterus.  In  this  condition  the  discharge  is  intermittent.  For 
a  number  of  days  the  flow  stops  and  then  a  free  discharge  of 
offensive  pus  takes  place. 

Complete  occlusion  of  the  canal  is  caused  by  adhesions  of 
the  disintegrated  mucous  membrane,  a  result  which  follows 
suppurative  inflammation  of  the  mucosa,  but  is  rarely  if  ever 
present  in  catarrhal  forms  of  inflammation.  Pus  accumu- 
lates above  the  stricture  and  distends  the  body  of  the  uterus, 
giving  rise  to  a  condition  which  resembles  an  abscess  in 
pathology  and  symptoms.  If  the  stricture  is  not  extensive 
the  pressure  will  force  it  open,  pus  will  be  discharged,  and 
there  will  be  repetitions  of  the  closure,  accumulation,  re- 
opening, and  the  discharge.  In  most  cases  it  is  necessary 
to  open  and  dilate  the  canal  before  relief  can  be  obtained. 
When  the  disease  has  existed  long  enough  to  destroy  the 
mucous  membrane  it  may  end  in  cicatrization ;  but  there  is 
a  marked  tendency  to  continued  suppuration.  The  disease 
can  hardly  be  called  self-limiting. 

In  nearly  all  the  cases  that  I  have  seen  in  which  there  had 
been,  for  a  time,  a  stenosis  of  the  canal,  the  uterus  had  become 
greatly  distended  and  prolapsed  or  retroverted.  The  cavity 
of  the  uterus  measured  three  and  a  half  inches  in  one  instance 
and  four  inches  in  another.  The  senile  atrophy  may  be 
delayed  by  the  presence  of  endometritis,  and  the  uterus  may 
remain  larger  than  it  should  be  in  old  age,  but  that  does  not 
account  for,  nor  is  it  like,  the  enlargement  from  distention. 
In  the  enlargement  of  the  cavity  from  distention  with  pus 
the  walls  become  very  thin,  while  in  the  other  the  normal 
thickness  of  the  walls  continues. 

32 


492  MEDICAL   GYNECOLOGY. 

Causation. — A  continuation  of  endometritis,  acquired  be- 
fore the  menopause,  accounts  for  a  certain  number  of  the 
cases,  especially  of  those  in  -which  the  disease  is  limited  to 
the  cervix.  Some  of  the  severer  forms,  in  which  the  disease 
involves  the  body  of  the  uterus,  are  caused  by  displacements, 
prolapsus,  or  retroversion,  especially  retroversion.  Prolapsus 
in  a  marked  degree  exposes  the  cervix  to  irritation,  and  if  it 
continues  for  long,  inflammation  and  ulceration  will  appear 
around  the  os  externum  and  extend  to  the  mucous  mem- 
brane of  the  canal.  The  atroi^hy  of  the  cervix  is  retarded,  or 
else  infiltration  takes  place  and  keeps  the  cervix  enlarged. 
These  cases  are  easily  controlled  if  the  displacement  can  be 
relieved.  Corporeal  endometritis  is  frequently  induced  by 
retroversion.  The  displacement  interrux)ts  the  esca]3e  of  the 
secretion  of  the  mucous  membrane  and  its  retention  causes 
decomposition  and  inflammation  of  a  purulent  variety.  Stric- 
ture at  the  OS  internum  i^roduces  inflammation  in  the  same 
way  as  retroversion,  and  the  two  are  often  found  together, 
but  in  the  majority  of  instances  the  occlusion  is  the  result  of 
the  inflammation. 

Acute  or  latent  gonorrhoea  may  cause  this  form  of  en- 
dometritis, but  I  am  not  sure  that  I  have  ever  seen  a  case  of 
acute  gonorrhoeal  endometritis  after  the  menopause.  Old 
neglected  cases  I  have  seen  several  times. 

Senile  vulvitis  and  vaginitis,  due  to  malnutrition  and  in- 
attention to  cleanliness,  extend  and  produce  endometritis  in 
advanced  life,  but,  as  the  latter  very  often  is  the  cause  of  the 
former,  it  is  difficult  to  decide  in  a  given  case  whether  the 
disease  began  in  the  uterus  or  vagina.  Fibromata  of  the 
uterus  act  as  a  very  important  cause  of  the  affection.  Al- 
though uterine  fibromata  frequently  disappear  after  the  meno- 
pause, the  endometritis  which  accompanies  the  neoplasm 
continues,  but  changes  from  a  catarrhal  to  a  purulent  form. 

One  patient  who  had  a  small  fibroid  passed  the  climac- 
teric and  was  free  from  all  uterine  disease  until  she  was  sixty 
years  old.  She  then  developed  an  endometritis  attended 
with  such  a  profuse  sero-purulent  discharge  that  she  sought 


SENILE  ENDOMETRITIS.  493 

relief  of  her  family  physician.  He  made  a  diagnosis  of  can- 
cer, and  she  was  brought  to  me  for  operation.  I  found  the 
remains  of  the  fibroid  in  the  cavity  of  the  uterus.  It  was  re- 
moved, and,  though  the  serous  element  of  the  discharge  sub- 
sided at  once,  the  endometritis  persisted  and  only  yielded  to 
treatment  after  several  months. 

I  have  often  wondered  why  the  surgeons,  who  charge  so 
much  against  fibromata,  such  as  their  danger  to  life  and 
health,  have  never  found  senile  endometritis  caused  by  them. 
Perhaps  tKey  have  overlooked  this  matter,  or  it  may  be  that 
these  are  cases  which  they  have  mistaken  for  cancer. 

Fibromata  cause  endometritis  after  the  menopause  by  de- 
laying senile  atrophy  and  also  by  sloughing,  which  takes 
place  in  rare  cases.  Catarrhal  endometritis  usually  accom- 
panies fibromata  and  changes  to  the  purulent  variety  after 
the  menopause,  as  already  stated.  Another  curious  fact  is 
that,  although  the  fibroid  that  causes  the  metritis  may  slough 
and  come  away,  or  become  pedunculated  and  the  surgeon 
remove  it,  the  metritis  continues.  This  is  the  opposite  to 
that  which  occurs  in  middle  life.  If  a  fibroid  is  removed  in 
a  young  subject  the  endometritis  usually  subsides  when  this 
cause  is  removed. 

I  saw  one  lady,  fifty-four  years  old,  who  had  a  submucous 
fibroid  of  the  uterus.  She  had  a  well-marked  endometri- 
tis, which  was  being  treated  without  benefit.  The  fibroid 
sloughed  and  was  completely  removed.  She  had  septicae- 
mia, from  which  she  recovered,  but  the  purulent  endometri- 
tis persisted,  and  only  yielded  to  treatment  after  long-con- 
tinued efforts.  I  supposed  that  the  metritis  in  that  case  was 
obstinate  owing  to  its  being  caused  by  sepsis,  but  I  found 
that  a  like  inflammation  might  be  set  up  with  only  the  pres- 
ence of  a  fibroid  to  account  for  it. 

A  patient  sixty  years  old  had,  judging  from  her  history,  a 
catarrh  of  the  uterus  at  the  menopause.  It  continued  in  a 
changed  form,  and  a  short  time  before  I  saw  her  she  became 
worse,  had  more  severe  pelvic  pains  and  tenesmus,  with  a  very 
free  sero-purulent  discharge.     I  expected  to  find  an  endome- 


494:  MEDICAL  GYNECOLOGY. 

tritis  and  prolapsus,  but  instead  found  a  small,  pedunculated 
fibroid  that  had  been  expelled  from  the  body  of  the  uterus 
and  occupied  the  dilated  cervix.  I  removed  it,  and  the  pa- 
tient was  relieved  and  improved,  but  the  endometritis  of  the 
purulent  form  continued,  and,  although  much  less  severe,  was 
difficult  to  cure. 

Finally,  a  form  of  inflammation  the  same  as  senile  endo- 
metritis occurs  when  the  ovaries  are  removed  in  patients  hav- 
ing endometritis.  After  the  ovaries  are  removed  the  existing 
endometritis  changes  to  the  senile  form  simultaneously  with 
the  atrophic  changes  which  follow  the  premature  menopause. 
The  presence  of  endometritis  is  a  reason  for  removal  of  the 
uterus  in  cases  requiring  double  ovariotomy",  but  those  who 
have  most  strongly  advocated  hysterectomy  in  this  connec- 
tion have  not  referred  to  this  indication  for  the  operation,  so 
far  as  I  know. 

Symptomatology. — The  symptom  which  first  attracts  at- 
tention is  a  discharge  which  varies  in  character  according  to 
the  extent  and  stage  of  the  inflammation.  When  a  cervical 
endometritis  is  present  at  the  menopause  the  characteristic 
leucorrhoea  gradually  disappears  or  else  changes  to  that  of 
the  senile  form  of  the  affection.  The  tenacious  secretion  of 
the  cervical  glands  is  replaced  by  a  sero-pnrulent  discharge 
which  is  more  like  a  vaginal  leucorrhoea.  The  discharge, 
sooner  or  later,  causes  a  subacute  or  senile  vaginitis  and  vul- 
vitis. There  is  very  often  prolapsus  of  the  vaginal  walls  and 
uterus  complicating  the  metritis  which  causes  pelvic  tenes- 
mus and  some  disturbance  of  the  vesical  and  rectal  functions. 

These  are  the  chief  symptoms  in  the  early  stage  of  this 
disease  when  prolapsus  is  the  only  complication.  When  the 
uterus  is  retroverted  and,  owing  to  imperfect  drainage,  the 
products  of  inflammation  accumulate  and  distend  it,  there 
is  more  pain  and  the  constitutional  disturbance  is  much  more 
defined.  There  is  often  a  rise  of  temperature  and  the  pulse 
increases.  The  digestion  is  also  deranged,  and  ultimate  nu- 
trition impaired  in  cases  of  long  standing.  This  is  due  to 
pain,  reflex  disturbance,  and  more  especially,  perhaps,  to  a 


SENILE  ENDOMETRITIS.  495 

slight  chronic  sepsis.  The  malnutrition  increases  the  appear- 
ance of  premature  old  age,  and  the  dry,  bronzed  appearance 
of  the  skin  is  suggestive  of  malignant  disease.  In  cases 
where  true  stenosis  takes  i^lace  at  the  os  internum  or  at  any 
point  in  the  canal  of  the  cervix  the  symptoms  are  usually 
very  pronounced.  The  pain  is  acute  and  compels  the  patient 
to  rest  in  bed.  It  differs  from  that  of  acute  pelvic  inflamma- 
tion in  being  slight  at  first  but  gradually  increasing,  while 
the  pain  of  acute  disease  is  violent  at  first  and  gradually 
subsides.  The  constitutional  disturbance  is  more  marked 
in  this  condition  or  complication  than  in  any  other.  There  is 
symptomatic  fever.  In  one  of  my  patients  the  temperature 
reached  102°  F.  I  have  already  stated  that  stenosis  may  be 
the  cause  or  consequence  of  the  metritis.  The  imprisoned 
secretion  and  broken-down  tissue  produce  the  inflammation, 
or  the  stenosis  may  be  produced  by  the  inflammation.  That 
accounts  for  the  fact  that  in  some  cases  the  distention  of  the 
uterus  and  the  symptoms  are  gradually  developed,  but  in 
others  they  come  on  somewhat  more  abruptly. 

Physical  Signs. — Inspection  shows,  in  nearly  all  cases, 
patches  of  inflammatory  redness  about  the  vulva  which  is 
peculiar  to  senile  vulvitis ;  the  contrast  between  the  red  por- 
tions and  the  anaemic  appearance  of  the  membrane  generally 
is  well  defined.  With  the  aid  of  the  speculum  the  signs  of 
the  same  form  of  vaginitis  are  observed.  Of  course,  the 
vagina  and  vulva  are  not  involved  in  all  instances,  but  as  a 
rule  they  are.  In  quite  a  few  it  has  been  limited  to  the 
upper  part  of  the  vagina,  and  mostly  to  the  vaginal  portion 
of  the  cervical  membrane. 

The  character  of  the  discharge,  which  is  of  much  value 
as  a  sign,  is  best  studied  through  the  speculum.  Indeed, 
upon  this  evidence,  senile  endometritis  is  distinguished  from 
other  troubles  and  forms  of  inflammation,  such  as  cancer  and 
gonorrhoea.  The  appearance  of  the  discharge  differs  from 
uterine  leucorrhoea  in  being  less  tenacious,  owing  to  the  ab- 
sence, in  varying  degrees,  of  the  secretion  of  the  glands  of 
the  cervix.     The  color  also  indicates  the  composition  to  be 


496  MEDICAL  GYNECOLOGY. 

sero-purulent,  and  in  this  it  is  more  like  the  outflow  in  spe- 
cific inflammation  and  is  similar  in  appearance  to  that  found 
in  the  early  stage  of  cancer. 

The  differentiation  between  the  discharge  in  senile  en- 
dometritis, specific  metritis,  and  cancer  must  be  made  by  the 
microscope  if  one  would  make  the  distinction  at  once — i.  e., 
without  waiting  for  the  full  development  of  the  history.  In 
senile  metritis,  pus,  serum,  disintegrated  tissue,  and  changed 
or  broken-down  epithelium  and  bacteria  are  found.  In  can- 
cer the  exuded  matter  is  sero-sanguinolent,  and  later  in  the 
progress  of  the  disease  contains  broken-down  necrotic  tissue 
and  elements  of  the  neoplasm.  The  gonorrhoeal  exudation 
can  be  distinguished  by  the  specific  germ  of  that  affection. 
Without  the  aid  of  the  microscope  it  is  impossible  to  make  a 
positive  diagnosis  between  the  specific  and  non-specific  ori- 
gin of  senile  endometritis,  but,  fortunately,  the  indications 
for  treatment  are  the  same,  whatever  the  cause  of  the  malady 
may  be.  The  history  may  show  that  gonorrhoea  is  the  proba- 
ble cause,  especially  if  the  disease  comes  on  abruptly,  was 
acute  at  the  start,  and  involved  the  vulva  and  urethra  first. 

The  differentiation  between  this  affection  and  cancer  of 
the  cervix  is  made  by  observing  that  in  cervical  endome- 
tritis there  is  the  characteristic  discharge,  degeneration  and 
atrophy  of  the  mucous  membrane,  and  in  cancer  there  is,  in 
addition  to  the  discharge,  infiltration  of  the  tissues — i.  e., 
neoplastic  growth.  When  the  disorder  is  fully  developed  in 
the  body  of  the  uterus  the  clinical  history  resembles  that  of  a 
malignant  disease,  but  can  be  readily  diagnosticated  by  the 
fact  that  pus  in  quantity  accumulates  in  the  cavity  of  the 
body  of  the  uterus  in  metritis,  while  that  never  occurs  to  the 
same  extent  in  cancer.  By  aspirating  the  uterine  cavity  the 
material  drawn  off  will  be  i3us  and  perhaps  a  little  blood, 
while  in  cancer  it  is  serum,  blood,  and  broken-down  cancer 
tissue.  The  aspiration  is  easily  made  by  using  a  small  curved 
pipette  with  a  rubber  bulb  at  the  end.  By  compressing  the 
bulb  and  introducing  the  pipette  and  removing  the  pressure, 
enough  material  can  be  withdrawn  to  show  its  character  and 


SENILE  ENDOMETEITIS,  497 

decide  tlie  diagnosis.  Of  course,  if  a  microscopical  examina- 
tion can  be  obtained  by  an  expert,  the  diagnosis  can  be  made 
with,  greater  certainty. 

The  history  of  the  progress  of  the  disease  aids  in  the 
diagnosis.  Cancer  progresses  steadily,  but  metritis  contin- 
ues about  the  same,  or  slowly  yields  to  such  treatment  as 
will  have  no  effect  in  retarding  or  curing  cancer.  Adenoma 
may  be  mistaken  for  senile  endometritis,  but  the  differential 
diagnosis  is  easily  made.  Adenoma  uteri  occurs  earlier  in 
life,  generally  about  the  menopause,  and  is  attended  with 
menorrhagia  or  metrorrhagia  as  the  most  marked  symptom. 
This  difference  is  diagnostic  because  menorrhagia  does  not 
occur  in  this  form  of  metritis.  There  is  not,  as  a  rule,  any 
purulent  discharge  in  adenoma.  By  using  a  small  curette  a 
portion  of  the  adenomatous  growth  can  be  removed  for  ex- 
amination which  will  complete  the  diagnosis. 

Treatment. — All  useful  means  should  be  employed  to  re- 
store the  general  health  by  tonics  and  good  diet.  Surgical 
treatment  is  the  most  important,  and  I  am  constrained  to  give 
it  here,  because  the  disease  is  not  treated  of  in  works  on  sur- 
gical gynecology.  When  the  disease  is  confined  to  the  cervix 
a  douche  of  a  solution  of  borax,  three  drachms  to  the  quart, 
gives  much  relief  and  prevents  the  discharge  from  keeping 
up  vaginitis.  Sulphate  of  zinc,  one  drachm  to  the  quart  of 
water,  is  very  effective  in  case  the  borax  fails.  The  hot- 
water  douche,  as  used  in  uterine  disease  generally,  is  not  of 
much  value  in  the  senile  form.  If  there  is  any  prolapsus  or 
other  displacement  it  must  be  corrected  by  the  use  of  medi- 
cated tampons  until  the  inflammation  is  relieved.  Sterilized 
absorbent  cotton  covered  with  boroglyceride,  glycerin,  and 
tannin,  or  white  vaseline,  answers  the  purpose.  I  have  tried 
prepared  wool  for  tampons,  but  it  is  more  irritating  and  has 
to  be  changed  more  frequently.  Astringent  and  alterative 
applications  are  useful  in  relieving  the  cervical  inflammation, 
but  any  caustics,  even  the  mildest,  do  harm  rather  than  good 
if  repeatedly  used.  I  have  most  faithfully  tried  carbolic  acid 
and  iodine,  which  are  so  effective  in  ordinary  metritis,  but 


498  MEDICAL  GYNECOLOGY. 

these  agents  are  not  satisfactory  in  the  senile  form  of  the 
disease.  One  or  two  applications  of  a  combination  of  car- 
bolic acid  and  tincture  of  iodine  may  do  good,  but  it  should 
not  be  repeated  many  times.  All  caustics  rather  encourage 
the  breaking  down  of  the  atrophded  tissue,  and  when  the 
slough  sex3arates,  the  surface  left  does  not  incline  to  heal,  but 
to  suppurate.  The  best  results  have  been  obtained  from  the 
use  of  boroglyceride  with  tannin,  glycerin  and  tannin,  fluid 
extract  of  liydrastis  canadensis,  and  a  mild  solution  of  acetic 
acid,  one  drachm  to  two  ounces.  Th.e  canal  should  be  thor- 
oughly washed  out  with  clean  water  and  th.e  application 
made  with  a  pipette. 

I  generally  begin  the  local  treatment  with  dilute  acetic  acid 
or  tincture  of  iodine  four  parts  and  carbolic  acid  one  part  ; 
an  application  of  either  of  the  above  twice  in  tlie  first  week. 
This  answers  the  best  wlien  the  discharge  is  very  free.  Fol- 
lowing this,  a  mixture  of  twenty  grains  of  tannic  acid  in 
an  ounce  of  boroglyceride  should  be  used,  but  as  this  is  a 
thickish  material  difficult  to  apply,  I  manage  by  warming 
the  mixture  and  using  a  pipette  with  an  opening  in  the 
end  as  large  as  the  size  of  the  glass  tube  will  admit.  Tan- 
nin and  glycerin  were  used  almost  entirely  some  years  ago  ; 
now  I  prefer  the  boroglyceride  and  tannin.  The  fluid  ex- 
tract of  hydrastis  canadensis  is  easily  used  and  lias  a  very 
good  effect,  and  I  fall  back  on  that  when  the  others  fail  to 
do  well.  Iodoform  is  the  most  efficient,  and  when  it  can 
be  freely  and  properly  applied  supersedes  all  other  agents. 
Indeed,  were  it  not  for  its  being  difficult  of  application  to 
the  canal  of  the  uterus,  it  would  meet  all  requirements.  I 
have  only  used  other  remedies,  such  as  I  have  mentioned, 
because  they  were  so  much  more  easily  applied  and  have 
not  the  offensive  odor  of  iodoform. 

I  was  first  led  to  use  iodoform  in  senile  endometritis  by 
observing  its  remarkable  effects  in  the  treatment  of  ulcers  in 
general  surgery.  Dr.  Fordyce  Barker  employed  it  in  cases  of 
cancer  of  the  uterus  with  great  benefit.  He  used  iodoform 
suppositories  made  in  convenient  form  to  introduce  into  the 


SENILE  ENDOMETRITIS.  499 

uterus.  The  results  wMch  lie  obtained  were  so  favorable 
that  I  am  now  inclined  to  believe  that  some  of  the  cases  he 
believed  to  be  cancers  were  really  cases  of  senile  endometri- 
tis. Many  gynecologists  have  made  that  mistake  in  diag- 
nosis, and  it  is  no  disparagement  to  suppose  that  Dr.  Barker 
may  have  occasionally  fallen  into  the  same  error.  I  pre- 
sumed that  the  effect  of  iodoform  was  due  in  a  measure  to 
its  antiseptic  qualities,  but  learned  that  it  was  not  a  germi- 
cide to  any  degree  sufficient  to  explain  its  effect  in  checking 
suppurative'  inflammation.  The  Bulletin  Generale  de  Thera- 
peutique  contains  a  full  discussion  of  the  subject  : 

' '  Maurel,  who  is  well  known  by  his  researches  on  the  leu- 
cocytes, has  undertaken  to  solve  the  problem  why  iodoform, 
which  is  so  efficacious  in  preventing  or  suppressing  sup- 
puration, should  apparently  have  so  little  action  on  the  pyo- 
genic staphylococci. 

"  He  first  experimented  with  a  virulent  culture  (on  gSlose) 
of  staphylococci  in  the  presence  of  leucocytes.  The  latter 
speedily  absorbed  the  staphylococci  but  succumbed  in  less 
than  two  hours.  In  the  control  field,  however,  they  accom- 
plish their  evolution  and  live  from  twelve  to  twenty-four 
hours.  Maurel  finds  that  the  death  of  the  leucocytes  under 
the  influence  of  the  pus  micro-organisms  is  due  to  a  toxine 
contained  in  the  bodies  of  these  microbes  ;  not  to  the  mechan- 
ical action  of  the  staphylococcus  or  to  the  products  which 
the  latter  yields  up  to  its  environment.  Under  the  influence 
of  these  same  staphylococci  the  red  corpuscles  become  dif- 
fluent in  fifteen  hours  and  then  disappear. 

"Another  series  of  experiments  were  made  by  subject- 
ing the  figured  elements  of  the  blood  to  the  action  of  iodo- 
form in  the  dosage  of  10  to  2-50  per  kilogramme  of  blood. 
Neither  the  smaller  nor  the  larger  doses  were  found  to  be 
toxic  to  the  leucocytes  ;  the  vital  activity  of  these  latter  was, 
on  the  contrary,  augmented,  and  the  action  on  the  red  glob- 
ules was  nil. 

"  A  third  series  of  experiments  show  iodoform  to  be  with- 
out marked  action  on  cultures  of  the  StapJiylococcus  au- 


500  MEDICAL  aYNECOLOGY. 

7'eus  and  albus.  In  a  fourth  series  of  researches  Maurel  sub- 
jected both  the  leucocytes  of  human  blood  and  cultures  of 
the  staphylococcus  to  the  action  of  iodoform  in  varying  pro- 
portions and  under  varying  conditions.  His  conclusions  are 
as  follows : 

"  1.  Iodoform  attenuates  the  virulence  of  the  staphylococ- 
cus. While  in  the  virulent  state,  this  micrococcus  kills  our 
leucocytes  in  less  than  two  hours  ;  when  it  is  subjected  along 
with  the  leucocytes  to  the  influence  of  iodoform,  the  latter 
preserve  their  movements  for  eight  hours,  at  least,  and  even 
complete  their  evolution. 

' '  2.  The  staphylococci  which  have  thus  lost  a  great  part 
of  their  virulence  (and  to  such  a  degree  that  they  are  seem- 
ingly devoured  by  the  leucocytes  with  impunity)  keep  all 
their  reproductive  energy  unimpaired,  so  that  virulence  and 
the  power  of  reproduction  are  independent  properties. 

"A  flnal  conclusion  is  deduced  that  it  is  in  both  these  ways 
— according  to  Maurel  it  is  by  augmenting  the  energy  of  the 
leucocytes  and  attenuating  the  virulence  of  the  pus  microbes — 
that  iodoform  opposes  suppuration,  which  is,  in  the  language 
of  bacteriology,  a  massive  slaughtering  of  the  leucocytes." 

These  teachings  are  in  harmony  with  clinical  experience 
as  to  the  benefits  of  iodoform  in  preventing  or  arresting  sup- 
puration. 

There  is  considerable  difficulty  in  applying  iodoform  to 
the  cavity  of  the  bodj^  of  the  uterus  in  sufficient  quantity  to 
be  effective.  Suppositories  made  with  cacao  butter  are  not 
retained  in  the  cervix,  and  while  they  remain  in  the  cavity  of 
the  body  for  a  time,  there  is  not  enough  retained  to  give  the 
full  effect.  I  have  used  a  solution  in  boiled  linseed  oil,  and 
also  an  ether  solution,  but  the  latter  causes  much  irritation 
and  the  former  does  not  hold  enough  of  the  iodoform.  The 
best  is  the  dry  fine  powder  which  can  be  introduced  through 
a  small  cannula.  The  next  best  (and  more  easily  introduced) 
is  the  fine  powder  held  in  suspension  in  acacia  and  water  by 
agitation  and  then  instilled  with  a  pipette. 

When  the  disease  (limited  to  the  cervix)  is  complicated 


SENILE  ENDOMETRITIS.  501 

with  scar  tissue  resulting  from  old  lacerations,  I  have  oper- 
ated with  the  result  of  relieving  some  of  the  neuralgic  pain 
and  with  benefit  to  the  inflammation.  It  is  difficult  to  get 
good  and  prompt  union.  In  fact,  some  of  the  operations 
have  been  failures. 

The  treatment  of  the  corporeal  form  of  this  affection  is 
rendered  more  difficult  by  certain  complications,  such  as  pro- 
lapsus, stenosis  of  the  canal,  or  retroflexion.  Complete  clos- 
ure of  the  canal  of  course  must  be  relieved  first  by  dilatation 
to  afford  room  for  washing  out  the  uterus  and  subsequent 
drainage.  When  the  stricture  is  at  the  os  internum,  time 
and  patience  are  necessary  to  open  the  canal.  This,  if  pos- 
sible, should  be  accomplished  by  dilating  the  canal  below 
the  stricture  and  then  pushing  a  very  fine  probe  through 
the  stricture.  There  is  danger  in  puncturing  it  with  a  knife, 
because  it  is  difiicult  to  determine  the  direction  of  the  canal, 
and  hence  danger  of  puncturing  the  wall  of  the  uterus. 
Gradual  dilatation  is  best.  Owing  to  the  friable  condition 
of  the  uterine  tissue,  laceration  is  sure  to  occur  if  forcible 
dilatation  is  practiced.  When  an  opening  has  been  made 
large  enough  to  pass  a  uterine  sound,  a  piece  of  gauze  should 
be  introduced  to  keep  the  parts  from  contracting.  Better 
still  is  a  tent  of  elm  bark,  carbolized  before  use.  This  tent  is 
bland,  sterile,  and  swells  a  little,  which  keeps  up  dilatation. 
When  the  cervix  is  dilatable,  the  canal  should  be  made  large 
enough  to  admit  a  reflux  catheter.  The  uterus  should  be 
w^ashed  out  with  a  five-per-cent  solution  of  carbolic  acid 
and  then  packed  with  iodoform  gauze.  The  packing  should 
be  left  in  forty- eight  hours  if  there  is  no  severe  pain  and 
rise  of  temperature.  Upon  removing  the  gauze  the  uterus 
should  be  washed  out  with  boiled  water  and  iodoform  powder 
introduced,  in  the  way  described  in  the  treatment  of  cervical 
endometritis.  Owing  to  the  difficulty  of  handling  iodoform, 
I  have  used  peroxide  of  hydrogen  and  found  it  very  useful. 
When  a  reliable  preparation  can  be  obtained  it  gives  most 
satisfactory  results,  providing  it  is  used  twice  or  three  times 
a  day. 


502  MEDICAT.  GYNECOLOGY. 

From  the  difficulty  of  obtaining  reliable  preparations  of 
peroxide  of  hydrogen  and  the  fact  that  it  is  easily  decom- 
posed by  heat  and  exposure,  I  have  lately  used  a  preparation 
called  pyrozone  made  by  McKesson  &  Robbins.  It  is  an 
aqueous  solution  of  dioxide  of  hydrogen.  A  three-per-cent 
solution  is  the  one  I  have  used,  but  I  have  not  had  sufficient 
experience  so  far  to  enable  me  to  say  that  this  pyrozone  is  all 
it  is  claimed  to  be. 

In  cases  complicated  with  retroversion  the  malposition 
must  be  corrected  in  order  to  be  able  to  w^ash  out  the  uterus 
thoroughly  and  to  keep  up  drainage.  The  treatment  of  retro- 
version is  very  difficult  when  the  vagina  is  contracted,  as 
it  usually  is  after  the  climacteric.  In  fact,  it  is  imjDossible  to 
replace  the  thin-walled  uterus  that  is  distended  with  the 
products  of  inflammation.  Thorough  dilatation  and  evacua- 
tion must  first  be  made,  and  then  by  the  use  of  a  tampon  or 
a  soft  ring  pessary  the  posterior  vaginal  wall  may  be  carried 
backward  far  enough  to  keep  the  fundus  uteri  from  falling 
downward  below  the  level  of  the  cervix.  Free  drainage  may 
be  obtained,  although  the  uterus  may  still  be  retroverted  in 
a  slight  degree.     Prolapsus  also  requires  to  be  corrected. 

Both  patient  and  surgeon  are  likely  to  become  discour- 
aged with  the  treatment,  which  is  sure  to  be  tedious,  espe- 
cially if  not  well  understood.  This  has  raised  the  question 
in  my  mind  whether  hysterectomy  would  not  be  justifiable 
in  the  worst  cases.  I  have  seen  the  uterus  removed,  sup- 
posedly for  cancer,  but  really  in  senile  endometritis,  and  the 
results  have  been  good.  Still,  I  would  prefer  to  employ  the 
treatment  recommended  here,  and  not  until  that  had  failed 
would  I  resort  to  hysterectomy. 

In  cases  of  senile  endometritis  complicated  with  complete 
prolapsus,  vaginal  hysterectomy  is  the  proper  treatment  in 
all  cases  excepting  in  those  whose  general  health  presents  a 
contra-indication.  Dr.  Edebohls  has  done  hysterectomy  in 
cases  of  complete  prolapsus,  and,  although  I  have  succeeded 
in  relieving  such  displacement  in  the  majority  of  cases  with- 
out removing  the  uterus,  I  resort  to  hysterectomy  without 


SENILE  ENDOMETRITIS.  503 

the  least  hesitation,  and  with  confidence  in  the  results,  in 
cases  of  senile  endometritis  and  complete  prolapsus. 

Senile  Vulvitis  and  Vaginitis. — An  ill-defined  form  of  inflam- 
mation of  the  vulva  and  vagina  occurs  not  infrequently  in 
aged  women.  These  affections  have  already  been  referred  to 
in  connection  with  senile  endometritis,  and  they  also  occur 
independently,  and  therefore  demand  a  brief  notice. 

Inflammation  of  the  vulva  and  vagina  of  the  senile  form 
appears  after  the  menopause,  of  course,  but  it  may  be  a  con- 
tinuation df  an  inflammation  that  existed  before  the  meno- 
pause, which  simply  changes  its  character  after  the  cessation 
of  the  menses.  As  a  rule,  the  inflammation  is  of  a  mild  type 
and  is  generally  follicular.  The  discharge  is  sero-purulent 
and  not  very  profuse.  The  mucous  membrane  is  a  bluish  red 
in  patches,  the  intervening  portion  being  smooth,  glazed,  and 
pale,  compared  with  the  inflamed  places.  In  severe  forms  of 
the  trouble  there  is  a  general  redness,  the  congestion  ap- 
pearing to  be  superficial.  In  all  cases  there  is  evidence  of 
the  senile  atrophy  which  has  taken  place.  The  nutrition  of 
the  tissues  is  defective,  esjDecially  in  the  very  aged. 

The  symptoms  are  a  discharge,  a  sensation  of  burning  in 
the  head,  smarting  after  urinating,  and  in  many  cases  pruri- 
tus, but  the  subjective  part  of  the  clinical  history  is  not  well 
defined  in  all  instances.  Many  patients  suffer  but  little,  but 
this  is  owing  to  the  diminished  sensitiveness  which  comes 
with  age.  In  some  of  the  most  marked  cases  the  patients 
complain  only  of  the  discharge  and  occasional  irritation.  In- 
spection reveals  the  appearances  given  above.  The  diagnosis 
is  made  by  excluding  malignant  disease. 

Causation. — Though  the  impaired  nutrition  which  comes 
with  advanced  age  predisposes  to  the  senile  form  of  infiam- 
mation,  want  of  cleanliness  appears  to  be  the  most  common 
direct  cause.  IN'eglect  to  keep  the  parts  clean  and  dry  is  very 
common  among  aged  women.  The  secretions  of  the  vulvo- 
vaginal glands  when  permitted  to  remain  and  decompose 
upon  the  tissues  are  quite  irritating  and  light  up  inflam- 
mation.    In  some  cases  vulvitis  and  vaginitis  are  secondary 


504  MEDICAL  GYNECOLOGY. 

to  urethritis  or  senile  metritis.  This  has  been  referred  to  in 
speaking  of  metritis,  but  vulvitis  and  vaginitis,  secondary  to 
urethritis,  have  had  less  attention.  I  have  noticed  that  the 
discharge  from  the  urethra  and  urethral  glands  will  prolong 
inflammation  of  the  vulva  indefinitely. 

Treatment. — Care  should  be  taken  to  determine  the  cause 
and  complications  if  any  are  present.  If  there  is  metritis, 
vt'hich  may  have  caused  the  vaginitis,  or  a  urethritis  that  is 
keeping  up  the  vulvitis,  these  should  have  first  attention. 
The  treatment  is  the  same  as  in  these  affections  in  younger 
subjects.  Thorough  cleansing  of  the  parts  two  or  three  times 
a  day  is  the  first  essential,  and  then  the  use  of  medicinal 
agents.  Stimulating  astringents  answer  better  than  caustics 
even  of  the  mildest  character. 

The  parts  should  be  thoroughly  cleansed  with  borax  and 
water  three  times  a  day,  and  each  time  followed  with  an 
application  of  a  solution  of  tannin  with  very  little  glycerin. 
Ten  grains  of  tannin,  seven  drachms  of  water,  and  one  drachm 
of  glycerin  answer  well.  Equal  parts  of  the  aqueous  fluid 
extract  of  hydrastis  canadensis  and  water  are  useful.  When 
these  do  not  act  promptly  I  make  apj)lications  of  balsam  of 
Peru  or  tincture  of  benzoin.  In  obstinate  cases  I  have  de- 
rived benefit  from  the  am monio- citrate  of  bismuth  solution. 

This  is  about  all  the  difference  between  the  senile  form 
of  vulvitis  and  vaginitis  and  that  which  occurs  in  early  life, 
both  as  regards  pathology  and  treatment. 


CHAPTER  XLI. 

PROLAPSUS   OF   THE   ABDOMIIS'AL   VISCERA   AND   PELVIC 

ORGAisrs. 

Prolapsus  of  the  Intestines  and  Omentum. — The  downward  dis- 
placement of  the  abdominal  viscera  differs  from  the  pendu- 
lous abdomen  due  to  a  relaxed  state  of  the  abdominal  mus- 
cles, which  are  generally  in  fair  condition  in  prolapsus.  In 
many  instances  I  have  found  the  abdomen  rather  flat  in  cases 
where  the  displacement  was  most  advanced. 

The  pathology  is  an  elongation  of  the  mesentery  and 
omentum.  As  a  rule,  both  the  bowels  and  omentum  are  pro- 
lapsed, but  occasionally  the  intestines  alone  are  found  out 
of  place.  The  anatomical  change  takes  place  slowly,  I  pre- 
sume, as  the  lesions  are  found  only  in  either  aged  or  feeble 
women.  The  effects  upon  the  intestines  are  first  passive  hy- 
persemia,  and  later  impaired  or  deranged  secretion  and  loss  of 
muscular  toncity  and  consequent  derangement  of  function. 

The  symptoms  are,  a  sense  of  dragging  in  the  abdomen 
and  a  feeling  of  weakness  or  want  of  support  in  the  gastric 
region.  American  women  sometimes  call  it  a  "gone  feeling," 
indicating  the  location  of  the  distress  by  placing  the  hand 
upon  the  epigastrium.  These  symptoms  are  all  increased  by 
walking  and  standing,  and  relieved  wholly  or  partially  by  the 
recumbent  position.  Irregular  intestinal  pains  are  generally 
present,  with  congestion  or  diarrhoea.  In  some  the  diarrhoea 
and  constipation  alternate. 

Physical  Signs. — Palpation  of  the  abdomen  shows  the 
absence  of  the  small  intestines  in  the  upper  part  of  the 
abdomen.     The  wall  of  the  abdomen  rests  upon  the  aorta, 

505 


506  MEDICAL   GYNECOLOGY. 

and  the  pulsation  is  so  distinct  that  it  suggests  aneurism. 
Owing  to  this  contact  of  the  wall  of  the  abdomen  with  the 
large  artery,  the  patient  is  conscious  of  the  pulsation  and 
often  complains  of  it  as  annoying,  especially  when  resting 
upon  the  back.  Bimanual  examination  of  the  pelvis  detects 
the  presence  of  the  intestines  and  omentum  in  the  sac  of 
Douglas.  The  intestine  can  usually  be  distinguished  by  the 
lightness  and  extreme  elasticity  due  to  the  presence  of  gas, 
which  gives  signs  to  the  touch  unlike  anything  else.  When 
the  intestine  contains  fecal  matter,  and  in  case  the  omentum  is 
prolapsed,  it  is  not  always  easy  to  make  out  the  true  condition. 

I  have  succeeded  in  making  a  diagnosis,  in  cases  where 
there  was  doubt  at  first,  by  the  simple  expedient  of  plac- 
ing the  patient  in  the  extreme  Trendelenburg  position,  or  the 
knee-chest  position,  and  then  the  intestines  and  omentum 
will  return  to  their  proper  place,  which  proves  conclusively 
the  nature  of  the  object  felt  in  the  pelvis.  When  compli- 
cated with  retroversion  of  the  uterus,  the  diagnosis  is  a  lit- 
tle more  difficult.  The  uterus  occupies  the  most  dependent 
portion  of  the  pelvis  and  drags  the  bladder  backward.  The 
prolapsed  intestines  rest  upon  and  above  the  uterus  and  blad- 
der and  can  be  felt  with  the  hand  upon  the  suprapubic 
region  only.  By  vaginal  touch  the  displaced  abdominal 
viscera  can  not  be  reached,  excepting  on  either  side  of  the 
uterus,  and  then  not  distinctly.  Placing  the  uterus  in  posi- 
tion and  keeping  it  there  permits  the  abdominal  viscera  to 
descend  into  the  sac  of  Douglas  and  remain  there  ;  then  the 
diagnosis  is  made  without  doubt  or  trouble. 

Causation. — Improper  use  of  corsets  and  the  position  of 
bending  over  in  reading  and  writing,  or  in  using  a  sewing 
machine,  predispose  to  this  displacement,  and  actually  pro- 
duce it  for  the  time  being.  The  viscera,  which  has  been  tem- 
porarily crowded  out  of  place,  will  become  replaced  upon 
resuming  a  normal  attitude  and  removing  the  tight  clothing. 
There  is,  however,  a  limit  to  this  recovery  of  position  by  the 
viscera,  and  that  is  reached  in  advanced  life,  when  the  tissues 
begin  to  undergo  the  senile  atro]Dhic  change  and  the  prolapsus 


PROLAPSUS  OF   THE  INTESTINES  AND   OMENTUM.  507 

becomes  continuous.  Diseases  of  the  liver  are  likely  to  aid  in 
causing  this  disorder  through  impaired  nutrition  of  the  ab- 
dominal viscera.  Dilatation  of  the  stomach,  I  think,  would  be 
likely  to  crowd  the  bowels  down  out  of  place  ;  but,  although 
I  have  found  both  of  these  affections  conjoined,  I  have  not 
concluded  that  the  one  acted  as  the  cause  of  the  other. 

Treatment. — The  indications  are  to  replace  the  viscera. 
This  is  accomplished  by  putting  the  patient  in  the  Trendelen- 
burg position  and  flexing  the  thighs ;  then  by  manipulation 
through  the  abdominal  wall  the  omentum  and  bowels  can  be 
raised  into  place.  In  some  of  the  worst  cases  it  is  necessary 
to  replace  by  bimanual  manipulation.  With  two  fingers  in 
the  vagina  the  intestines  can  be  pushed  up  out  of  the  pelvis, 
and  with  the  left  hand  upon  the  abdomen  they  can  be  carried 
into  the  abdominal  cavity.  Once  out  of  the  pelvis,  if  the 
wall  of  the  abdomen  is  relaxed,  they  can  be  held  in  place 
for  a  time  with  a  proper  abdominal  support,  which  should 
be  applied  while  the  patient  is  still  in  the  position,  with  the 
trunk  inclined  toward  the  head.  The  best  support  that  I 
have  found  is  a  flannel  bandage,  with  two  perineal  straps  to 
keep  it  from  slipping  up.  Under  the  bandage  and  above  the 
pubes  should  be  placed  a  pad  of  absorbent  cotton.  The  band- 
age should  be  tightly  pinned  with  safety  pins,  introduced 
parallel  to  the  median  line  of  the  body,  and  close  together. 
Rest  in  bed  is  necessary  for  a  time  at  the  beginning  of  the 
treatment. 

When  improvement  is  noted,  the  patient  should  be  per- 
mitted to  sit  up,  after  adjustment  of  the  bandage,  for  a  time 
each  day.  The  clothing  about  the  waist  should  be  perfectly 
free.  The  knee-chest  position  should  be  practiced  several 
times  each  day,  and  a  few  short  rests  taken  in  the  reclining 
position.  The  bowels  should  be  kept  free.  Replacement, 
support,  and  postural  treatment,  together  with  massage,  ton- 
ics, faradization,  and  general  tonic  and  restorative  manage- 
ment, give  relief  in  the  majority  of  cases.  Complete  relief 
may  be  obtained  in  the  case  of  young  women,  but  in  that 
of  the  aged  recovery  is  seldom  if  ever  attained. 

33 


508  MEDICAL  GYNECOLOGY. 

Senile  Prolapsus  of  the  Pelvic  Organs. — In  aged  women  pro- 
lapsus of  the  vaginal  walls,  bladder,  and  uterus  occurs  quite 
frequently.  Descent  of  the  pelvic  organs  differs  in  causa- 
tion, pathology,  and  treatment  from  such  affections  when 
they  occur  in  middle  life.  Prolapsus  at  this  period  comes 
from  atrophy  of  the  muscular  tissue  of  the  vagina  and  pelvic 
floor,  and  is  not  relieved  by  surgical  treatment,  as  in  middle 
age  ;  hence  the  discussion  of  the  subject  is  appropriate  in  this 
work. 

Two  classes  of  cases  have  come  under  my  observation : 
First,  those  who  have  borne  children  and  have  sustained  some 
slight  injuries  of  the  pelvic  floor,  and  imperfect  involution  of 
the  uterine  ligaments.  These  lesions  following  child-bearing 
are  not  sufficient  to  cause  prolapsus  until  atrophy  takes  place 
after  the  menopause.  This  class  of  cases  occupies  an  inter- 
mediate position  between  the  displacements  of  middle  life 
and  those  of  the  more  aged  patients. 

The  second  class  comprises  those  who  have  had  chil- 
dren and  pass  the  menopause  without  trouble,  but  develop 
displacements  in  advanced  life,  and  those  who  have  not  had 
children,  and  have  not  been  subjected  to  the  usual  causes  of 
prolapsus  of  the  pelvic  organs.  In  fact,  I  have  seen  this 
affection  in  aged  maidens  who  had  never  had  any  disease  of 
the  sexual  organs.  One,  I  remember,  was  over  seventy  years 
of  age,  and  the  hymen,  although  greatly  stretched,  was  still 
intact. 

Symptomatology. — In  the  majority  of  cases  the  patient 
first  notices  a  dragging-down  feeling  in  the  pelvis  on  standing 
or  walking.  The  bladder  is  often  irritable,  and  hence  there 
is  frequent  urination.  Rectal  tenesmus  is  sometimes  present 
and  is  annoying,  especially  in  those  who  have  rectal  haemor- 
rhoids.  As  the  trouble  progresses  the  vaginal  walls  begin 
to  protrude  from  the  vulva.  This  protrusion  gradually  in- 
creases and  becomes  troublesome  when  exercise  is  taken.  In 
some  there  is  irritation  of  the  vaginal  mucous  membrane, 
which  leads  to  a  subacute  form  of  vaginitis.  The  bladder 
and  rectum   suffer  more.     Urination,  at  first  frequent,  be- 


SENILE  PROLAPSUS  OF   THE  PELVIC  ORGANS.  509 

comes  difficult,  and  in  advanced  cases  the  bladder  is  never 
fully  emptied.  The  retention  of  a  certain  quantity  of  urine 
causes  decomposition  and  eventually  cystitis.  There  is  in 
some  cases  partial  incontinence  ;  in  others  defecation  is  diffi- 
cult. All  these  symptoms  being  aggravated  by  exercise,  the 
patient  naturally  keeps  quiet,  if  possible,  and  that  favors 
malnutrition  and  more  complete  atrophy, 

PJiysical  Signs. — Inspection  shows  a  relaxed  state  of  the 
pelvic  floor,  which  sags  down  below  its  normal  elevation. 
The  vagindl  walls  protrude  more  or  less  according  to  the  de- 
gree of  displacement.  Digital  examination  shows  the  vaginal 
walls  to  be  atrophied  ;  they  are  thin  and  lacking  in  muscular 
tissue.  The  uterus  is  small  and  there  is  no  invagination  of 
the  cervix  excepting  in  cases  of  laceration  and  hyperplasia, 
when  the  cervix  may  be  large  for  a  senile  uterus.  In  other 
cases  there  is  no  portion  of  the  cervix  found  in  the  vagina, 
but  in  place  of  the  cervix  there  is  a  contracted  condition  of 
the  upper  part  of  that  canal,  owing  to  scar  tissue.  There  is 
a  puckered  condition  of  the  vagina,  which  forms  a  cul-de-sac 
below  the  cervix  uteri.  The  cellular  tissue  in  the  pelvis  is 
absent  as  a  rule,  which  gives  an  impression  on  touch  exami- 
nation that  the  pelvis  is  empty,  in  consequence  of  the  extra- 
ordinary atrophy  of  the  muscular  and  areolar  tissue. 

Causation. — Sedentary  habits  and  impaired  nutrition  are 
the  chief  predisposing  causes  of  this  exaggeration  of  the 
atrophy  which  occurs  in  old  age.  Maintaining  the  sitting 
posture  for  a  great  part  of  the  time,  a  common  habit  among 
many  aged  women,  is  very  effective  in  causing  the  affection. 
Constipation  and  delay  in  emptying  the  bladder  aid  in  the 
causation.  Those  of  active  habits,  who  from  necessity  have 
to  be  upon  their  feet  all  day,  are  often  affected.  In  hospital 
practice  I  have  found  senile  prolapsus  among  the  very  poor, 
hard-working  women  of  all  nations. 

Treatment. — When  prolapsus  has  been  well  established  it 
can  not  be  cured.  Especially  is  this  the  case  if  the  patients 
are  well  advanced  in  years.  I  have  seen  a  large  number 
operated  upon,  and,  although  a  little  temporary  relief  was 


510  MEDICAL  GYNECOLOGY. 

afforded,  the  trouble  returned  in  time.  It  is  far  more  easy 
to  prevent  prolapsus  in  the  aged  than  to  manage  it  when 
fully  established.  Much  relief  can  be  given  and  the  patient 
made  comfortable  by  treatment.  When  the  first  symptoms 
appear,  astringent  douches  should  be  used.  A  solution  of 
sul]Dhate  of  zinc  or  tannic  acid  will  do  best.  This  and  rest 
after  short  periods  of  exercise  often  give  complete  relief.  It 
is  seldom,  however,  that  one  sees  such  cases  until  they  are 
well  advanced  ;  then,  in  addition  to  the  douche,  tampons  are 
necessary — a  small  tampon  of  absorbent  cotton,  medicated 
with  tannin  and  glycerin,  boroglyceride,  or  five  'per  cent  of 
ichthyol  in  glycerine. 

During  this  treatment  the  patient  should  wear  a  perineal 
pad  and  strap  while  exercising.  When  the  prolapsus  yields 
to  the  tampon  and  douching,  so  that  a  small  tampon  is  suf- 
ficient, a  pessary  should  be  tried.  I  have  found  Peaslee's 
ring  very  efficient.  A  small  size  should  be  used — one  that 
fits  loosely,  as  the  delicate  vaginal  walls  wiU  not  bear  pressure. 
The  perineal  band  ought  to  be  used  for  a  time  after  the  pes- 
sary is  introduced,  because  there  is  danger  of  its  coming 
away.  The  douche  should  be  continued,  and  the  patient 
directed  to  push  the  pessary  up  after  exercise  as  long  as  it 
inclines  to  come  down.  Such  cases  must  be  kept  under 
observation  after  they  are  relieved,  because  the  soft-rubber 
pessary  requires  to  be  changed  and  cleaned  every  month  or 
two. 

If  the  prolapsus  is  accompanied  with  senile  endometritis, 
cystitis,  or  prolapsus  of  the  abdominal  viscera,  these  troubles 
should  be  treated  at  the  same  time.  Constipation  and  gen- 
eral debility  are  generally  present  and  must  have  due  at- 
tention. 

I  deem  it  necessary  to  add  that  I  have  known  this  treat- 
ment by  mechanical  support  to  fail  and  in  some  cases  do 
much  harm,  owing  to  the  fact  that  the  tampons  employed 
were  too  large,  and  by  failing  to  use  douches  when  the  tam- 
pon was  changed.  Pessaries  also  do  harm  if  the  size  used  is 
too  large  or  the  rim  of  the  ring  too  small. 


CHAPTER  XLII. 

VARICOSE  VEIlSrS   OF  THE  PELVIS. 

A. 

The  pelvic  veins  are  especially  predisposed  to  overdis- 
tention,  for  the  reason  that  they  are  without  valves,  are  not 
supported  by  muscles,  fascia,  and  integument,  as  in  the  ex- 
tremities, and  are  under  constant  pressure  while  the  woman 
is  in  the  erect  position.  While  a  student  of  medicine  I 
witnessed  a  demonstration  of  the  anatomy  of  the  pelvic 
floor,  by  Prof.  Corydon  L.  Ford,  in  a  subject  in  which  the 
pelvic  veins  were  distended  to  a  degree  that  was  quite  ab- 
normal. Attention  was  especially  called  to  this  condition, 
and  suggestions  made  regarding  the  trouble  to  which  it 
might  give  rise.  Since  then  I  have  kept  the  matter  in  mind 
while  engaged  in  practice,  and  am  well  satisfied  that  this 
varicose  state  of  the  veins  is  not  uncommon  and  is  the  cause 
of  much  sujffering. 

There  is  little  in  the  literature  of  medicine  upon  the  sub- 
ject, excepting  that  Winckel  in  his  work  on  gynecology  re- 
fers to  this  condition  of  the  pelvic  veins  in  relation  to  uterine 
diseases. 

Dr.  D  wight  mentions  having  found  it  in  one  of  his  sub- 
jects which  he  had  dissected.  Barnes,  Klob,  and  Brandt 
have  found  phleboliths  in  the  pelvis,  and  suggested  that 
their  occurrence  in  this  location  was  probably  due  to  the  ab- 
sence of  valves  in  these  veins. 

A  most  valuable  article  on  this  subject  (the  only  thing  of 
practical  importance  that  I  have  found)  was  issued  by  my 
friend  Dr.  A.  Palmer  Dudley,  of  New  York,  in  1888.  He 
names  it  varicocele  in  the  female,  and  discusses  the  subject 


512  MEDICAL   aYNECOLOGY. 

with  special  reference  to  its  surgical  treatment.  I  have  been 
able  to  verify  all  that  Dr.  Dudley  has  said,  and  now  propose 
to  consider  the  subject  from  that  standpoint,  without  dwell- 
ing upon  the  anatomy  of  the  vessels  further  than  to  recall 
the  fact  that  the  pampiniform  plexus  is  located  upon  the 
posterior  surface  of  the  broad  ligaments,  and  that  it  is  in  this 
plexus  that  the  lesions  are  most  frequently  found.  In  some 
of  the  worst  cases,  however,  the  varicose  condition  involves 
all  the  pelvic  veins.  This  I  have  pointed  out  in  my  work  on 
injuries  of  the  pelvic  floor,  in  which  I  show  that  the  so-called 
rectocele  is  very  often  a  mass  of  varicose  veins.  The  fact  re- 
mains that  this  plexus  is  most  frequently  the  part  involved. 
Both  sides  are  affected,  but  occasionally  it  is  unilateral,  and 
generally  on  the  left  side.  It  occurs  most  frequently  in  mid- 
dle life.  I  have  never  seen  it  in  any  one  under  twenty-iive 
or  over  sixty  years  of  age,  but  it  possibly  may  occur  later  in 
life  than  I  have  ever  found  it. 

The  first  effect  of  this  distention  of  the  veins  is  to  cause 
pressure  upon  the  pelvic  tissues  and  nerves,  giving  rise  to 
dull  pain  and  pelvic  tenesmus.  The  continued  derangement 
of  the  circulation,  in  time,  develops  disease  of  the  pelvic 
organs  generally.  First,  perhaps,  the  ovaries  suffer ;  next 
the  rectum  ;  and  finally  the  uterus  and  bladder. 

In  many  cases  diseases  of  the  pelvic  organs  generally  may 
precede  or  take  place  simultaneously  with  the  varicosity  of 
the  veins  ;  but,  no  matter  whether  the  one  or  the  other  takes 
precedence,  the  lesions  of  the  veins  aggravate  the  other  af- 
fections. Dr.  Dudley,  in  his  article  referred  to  above,  gives 
a  very  clear  illustration  of  this  point.  Here  is  what  he  says 
in  speaking  of  his  third  case  treated  by  operation  : 

"  This  was  the  third  case  in  which  I  had  made  a  diagnosis 
of  varicocele  in  the  broad  ligament,  and  performed  laparot- 
omy for  its  removal.  It  was  the  most  obscure  of  the  three, 
the  varix  being  the  smallest,  and  on  that  account  I  deter- 
mined to  have  a  careful  microscopical  examination  of  the 
specimen  made,  to  either  confirm  or  invalidate  my  diagnosis. 
I  gave  the  specimen  for  examination  to  Prof.  Porter,  of  the 


VARICOSE  YEIXS   OF   THE   PELVIS.  513 

Post-Graduate  School,  who  had  sections  of  it  mounted  and 
drawings  made  from  them  for  me.  The  following  is  his  re- 
port in  full : 

"  ^  Pampinocele. — Upon  microscopical  examination  of  the 
ovaries,  tubes,  and  broad  ligaments  removed  by  Dr.  Dudley, 
the  following  conditions  were  found  :  First,  the  ovaries  were 
slightly  enlarged  and  the  seat  of  a  few  small  cysts,  some  of 
which  were  filled  with  a  clear  serum  and  others  with  a  semi- 
gelatinous  substance.  The  stroma  of  the  ovary  was  com- 
posed of    6rdinary   white  fibrillated  connective-tissue  sub- 


III  \\  _  ' 


Fig.  23. 

Stance  (Fig.  22,  a),  smooth  muscular  fibers,  and  blood-vessels. 
The  walls  of  the  arterioles  and  small  arteries  in  the  stroma 
were  generally  thickened  (Fig.  22,  b)  ;  in  some  the  lumen  was 
diminished,  while  in  others  it  was  expanded.  This  condition 
would  naturally  disturb  the  nutritive  supply  to  the  gland, 
and  tend  to  produce  a  capillary  engorgement. 

"'Second,  the  Fallopian  tube  presented  no  special  ab- 
normity. 

"'Third,  the  most  marked  pathological  changes  were 
found  in  the  substance  of  the  broad  ligament ;  the  pampini- 


514 


MEDICAL  GYNECOLOGY. 


form  plexus  was  in  a  state  of  marked  congestion,  the  walls  of 
the  vessels  were  thickened,  and  their  course  was  unusually 
tortuous.  That  this  engorgement  was  of  long  duration  is  sus- 
tained by  the  condition  of  the  capillaries,  which  were  found, 


1 


1 


lilte;M(Mrl!:i;ii;/s:'' 


4'''''!!;4''^'i'f!iii''i'''^'3i^'''''^'''i'''''*'''^*''''''^ 


h  e 

Fig.  23. 


upon  microscopical  examination,  to  be  enormously  distended 
and  filled  with  blood  in  a  state  of  partial  pigmentary  degen- 
eration (Fig.  23,  &),  indicating  considerable  duration  of  the 
stasis.  Under  ordinary  circumstances  the  capillaries  collapse 
and  can  not  be  distinguished  from  the  fibrillated  connective 
tissue  in  which  they  are  imbedded  unless  an  artificial  injec- 
tion is  made,  or  they  are  distended  with  blood  as  the  result 
of  an  acute  or  chronic  congestion.  Had  the  congestion  been 
acute  in  character  the  capillaries  would  have  been  distended 
Avith  red  and  white  corpuscles,  which  could  be  readily  recog- 
nized as  such.  But  in  this  case  it  was  difficult  to  make  out 
the  corpuscles,  but  the  vessels  were  very  much  distended  by 
the  blood-pigment  matter,  showing  clearly  that  the  engorge- 
ment was  of  long  duration  or  chronic  in  nature. 

"'The  walls  of  all   the  veins  were  thickened  and  their 


VARICOSE  VEINS  OF  THE  PELVIS. 


515 


course  was  quite  tortuous,  as  we  commonly  see  in  varicose  con- 
ditions (Fig.  23,  d).  The  walls  of  the  arteries  were  very  much 
thickened ;  in  some  the  lumen  was  contracted  (Fig.  23,  e),  in 
others  it  was  expanded  (Fig.  24,  h).  This  condition  would 
naturally  cause  an  irregular  pressure  to  be  maintained  in  the 
capillaries,  and  act  as  an  element  in  producing  the  capillary 
engorgement  (Fig.  24,  c),  which,  together  with  the  chronic  con- 
gestion of  the  veins,  explains  the  stagnation  and  pigmentary 
degeneration  in  the  capillaries.  The  sections  were  made  by 
Dr.   Crowell,   and   the  drawings  made   from   them   by  Dr. 


m     /^??  //  --^r  ////'//'  '//#// /,»y///  'IW" '  r  'I  ''T'^^'V^^^I 


aL 


i/ 


m  _  y. 


Pig.  24. 


George  G.  Van  Schaick  represent  very  accurately  the  great 
capillary  , congestion  and  thickening  of  the  blood-vessels." 

The  symptoms  are  not  clearly  defined,  perhaps  I  should 
say  they  have  not  been  thoroughly  studied,  owing  to  the 
fact  that  uncomplicated  cases  are  rare.  There  are  very  often 
other  affections  of  the  pelvic  and  abdominal  organs  pres- 


516  MEDICAL  GYNECOLOGY. 

ent  wMch  cause  suffering,  and  lience  certain  symptoms. 
Pelvic  pain  of  a  dull,  aching  character,  which  becomes  more 
severe  the  longer  the  patient  maintains  the  upright  position 
and  is  relieved  by  lying  down,  is  the  most  prominent  symp- 
tom. A  general  pelvic  and  rectal  (sometimes  vesical)  tenes- 
mus accompanies  the  p»ain  and  is  similarly  influenced  by  the 
position  of  the  patient.  The  symptoms  of  other  affections 
which  may  be  present— such  as  ovaritis,  rectal  haemorrhoids, 
or  old  pelvic  adhesions — are  characteristic  of  such  disorders 
and  indicate  their  presence. 

Some  help  is  found,  in  complicated  cases,  in  observing 
that  any  of  the  pelvic  diseases  which  may  be  present  are  ag- 
gravated by  the  varicose  veins.  For  example,  ovaritis  gives 
rise  to  characteristic  ovarian  pain,  which  is  slightly  modified 
by  position,  but  is  greatly  increased  by  the  presence  of  vari- 
cose veins.     So  it  is  in  any  uterine  disease. 

The  physical  signs  are  the  most  valuable  aids  to  diagnosis. 
Bimanual  examination  reveals  a  fullness  in  the  broad  liga- 
ments, distinguished  from  the  results  of  inflammation  by  be- 
ing not  acutely  tender,  but  doughy,  elastic,  and  fluctuating 
so  far  as  changing  place  by  pressure.  The  most  character- 
istic sign  is  the  change  in  volume  by  altering  the  patient's 
position.  If  a  bimanual  examination  should  be  made  in  the 
erect  posture,  both  by  vagina  and  rectum,  and  then  in  the 
exaggerated  Trendelenburg,  the  difference  in  volume  of  the 
veins  is  easily  noted. 

The  diagnosis  is  made  by  excluding  hydrosalpinx,  small 
cystic  ovaries,  prolapsed  intestines,  and  omentum.  The  dis- 
tended tubes  and  cystic  ovaries  are,  as  a  rule,  more  tender 
and  are  not  changed  by  change  of  position  of  the  patient, 
and  pressure  does  not  dispel  the  mass.  The  prolapsed  ab- 
dominal viscera  can  be  raised  up  and  out  of  the  pelvis  and 
thereby  excluded.  Varicose  veins  are  frequently  mistaken 
for  distended  tubes.  In  my  early  observations  I  was  led  to 
make  this  mistake  in  diagnosis,  and  others  I  know  have  erred 
in  a  similar  way.  One  patient,  who  suffered  from  chronic 
ovaritis,  was  examined  by  two  well-known  experts,  who  made 


VARICOSE  VEINS  OP  THE  PELVIS.  517 

a  diagnosis  of  diseased  tubes  and  ovaries.  In  operating  I 
found  both  ovaries  cirrhotic,  the  tubes  were  normal,  but  the 
veins  were  greatly  enlarged,  one  or  two  being  large  as  the 
middle  finger  or  larger. 

Causation. — Age,  occupation,  and  unsuitable  clothing 
predispose  to  this  disease.  The  latter  part  of  the  period  of 
active  sexual  function  is  the  time  when  it  occurs,  and  seden- 
tary habits,  tight  clothing,  and  maintaining  the  erect  position 
too  long  favor  this  condition.  Excessive  activity,  especially 
sexual  excitation  long  continued  and  unsatisfied  ;  subinvo- 
lution after  miscarriage  or  confinement  at  term  ;  and  lacera- 
tion of  the  levator  ani  muscle,  causing  a  sagging  in  the  pel- 
vic floor,  no  doubt,  are  the  most  direct  and  frequent  causes. 
Disease  of  the  pelvic  organs  often  favors  this  change  in  the 
pelvic  vessels,  but,  on  the  other  hand,  it  is  as  likely  that  cer- 
tain disorders  of  the  uterus  and  ovaries  may  be  caused  by  the 
varicose  veins. 

Any  and  all  things  that  favor  congestion  of  the  pelvis  by 
interrupting  or  retarding  the  return  circulation  will  cause 
overdistention  of  the  veins.  All  these  influences  are  referred 
to  in  tracing  the  causes  of  some  of  the  uterine  and  ovarian 
diseases  in  which  congestion  is  a  prominent  element.  Those 
less  likely  to  be  thought  of,  and  that  are  not  referred  to 
in  writings  on  the  subject,  are  hepatic  and  intestinal  diseases 
which  retard  the  portal  circulation — the  same  conditions 
which  cause  rectal  haemorrhoids.  I  have  observed  that  gen- 
eral, and  to  a  lesser  extent  pelvic,  peritonitis,  in  some  cases, 
causes  this  malady  by  obstructing  the  veins  in  the  abdomen 
or  high  up  in  the  pelvis. 

I  have  seen  this  varicose  condition  of  the  pelvic  veins  most 
frequently  in  those  who  had  borne  children,  had  been  of 
sedentary  habits,  or  were  obliged  to  stand  much  of  the  time, 
and  who  had  some  of  the  more  common  uterine  disorders. 

It  would  appear,  from  this,  that  subinvolution  after  par- 
turition and  unfavorable  circumstances  of  life,  or  occupation, 
were  the  major  causes. 

Treatment. — The  question  naturally  arises,  Does  this  con- 


518  MEDICAL  GYXECOLOGT. 

dition  tend  to  recovery,  to  increase  and  give  rise  to  other 
affections,  or  to  remain  a  permanent  disease  which  impairs 
the  comfort  and  usefulness  of  the  individual  ?  The  natural 
history  has  not  yet  been  fully  recorded.  In  fact,  there  is  not 
much  said  about  it,  and,  although  I  have  been  investigating 
the  matter  for  some  years,  there  are  many  things  that  I  am 
not  sure  about.  I  am  inclined  to  believe,  from  what  I  have 
seen,  that  after  the  menopause  there  is  a  marked  improve- 
ment in  many,  and  perhaps  recovery  in  a  certain  number,  but 
apart  from  this  the  affection  has  no  natural  tendency  toward 
recovery. 

The  effective  treatment  is  removal  of  the  veins,  the  whole 
plexus,  or  as  much  of  it  as  can  be.  I  have  operated  with 
very  gratifying  results,  and  sufficiently  often  to  commend  the 
surgical  treatment,  when  the  suffering  is  severe  enough  to  call 
for  it. 

Dr.  Dudley's  results  in  four  cases  are  sufficient  to  give 
the  operation  a  merited  place  in  gynecological  surgery. 
There  are  cases  where  operation  is  not  urgently  indicated, 
that  can  be  greatly  helped  by  treatment. 

First,  it  is  necessary  to  see  that  the  bowels  act  promptly 
and  that  there  is  no  constriction  of  the  waist.  Displace- 
ments of  the  pelvic  organs  should  be  corrected.  In  case  the 
pelvic  floor  is  defective  from  injuries,  it  should  be  restored. 
Of  course,  any  disease  of  the  pelvic  organs  which  may  be  pres- 
ent should  be  treated  simultaneously.  Astringent  douches 
and  the  tampon,  with  boroglyceride,  are  useful,  and  a  large- 
rimmed  Peaslee  ring-pessary  gives  support  to  the  uterus, 
and  by  pressure  relieves  the  pain  in  certain  cases.  It  should 
be  used  after  the  tampon,  and  after  the  patient  is  able  to  be 
about  on  her  feet. 

The  most  valuable  part  of  the  whole  management  is  rest, 
with  the  pelvis  elevated.  At  night  the  patient  should  have 
the  pelvis  raised  when  resting  on  the  back  ;  and  while  upon 
the  side  take  Sims's  position,  only  more  prone — that  is,  the 
upper  knee  should  be  placed  forward  and  over  the  lower 
until  it  touches  the  bed.     During  the  day  the  Trendelen- 


VARICOSE   VEINS  OP  THE  PELVIS.  519 

burg  position  should  be  taken  while  resting.  So  much  relief 
is  usually  obtained  that  the  patient,  when  once  she  has  ex- 
perienced the  benefit  of  it,  will  be  glad  to  follow  out  this  part 
of  the  treatment. 

Finally,  the  use  of  electricity  I  commend  very  highly. 
The  interrupted  high-voltage,  primary,  or  mixed  current,  as 
introduced  into  practice  by  Dr.  George  J.  Engelmann,  gives 
great  relief.  This  peculiar  electric  current,  as  used  by  Dr. 
Engelmann,  has  been  found  by  many  to  relieve  pelvic  pain, 
hasten  the  absorption  of  inflammatory  products,  and  improve 
nutrition,  and  I  have  found  it  of  great  service  in  quieting  the 
distress  caused  by  varicose  veins.  I  also  believe  that  it  con- 
tracts the  vessels  in  some  degree,  or  improves  the  nutrition 
of  their  walls,  so  that  they  regain  their  tonicity. 

I  have  used  electricity  in  connection  with  other  means, 
especially  postural  treatment,  and  therefore  I  can  not  fairly 
say  how  much  of  the  benefit  can  be  credited  to  the  electricity, 
but  am  sure  that  it  is  a  valuable  agent  in  the  management  of 
this  trouble. 


INDEX. 


Abdomen,  original  anatomy  of,  165. 

solid  tumors  of,  170. 
Abdominal  massage,  136. 

viscera,  prolapsus  of,  505. 
Abnormal  urine,  454. 
Alcohol  in  gynecology,  141. 
Alimentation  forcee,  144. 
Araenorrhoea,  179. 

Anatomical    characteristics   of    women, 
65. 

of  chlorosis,  57. 

of  menstruation,  38. 
Anatomy  and  physiology  for  girls,  33. 
Anatomy  of  pelvic  organs,  235. 
Anderson,  Dr.  W.,  on  use  of  eucalyptus 

globulus,  461. 
Areolar  hyperplasia  of  mammary  glands, 

355. 
Armour  on  urinary  troubles,  414. 
Ascitic  fluid,  170. 

Barker,  Dr.  Fordyee,  on  the  use  of  ni- 
trous-oxide gas,  340. 
Baruria,  418. 
Beard,  George  M.,  M.  D.,  on  neurasthenia, 

305. 
Beef  juices  for  the  sick,  142. 
Bertkan,  Dr.,  on  bisexual  characteristics 

in  insects,  18. 
Bibra  on  brain  tissue,  482. 
Bladder,  function  of,  378. 
functional  diseases  of,  384. 

due  to   abnormal  condition  of  the 
urine,  411. 

to  abuse  of  sexual  function,  388. 

to  hyperfemia,  434. 

to  hysteria,  399. 

to  ovarian  affections,  436. 


Bladder,  functional  diseases  of,  charac- 
teristics of,  411, 
causation,  413. 

diagnosis,  413. 
illustrative  case,  416. 
prognosis,  413. 
symptomatology,  413, 
treatment,  414. 
alkaline  carbonates,  414. 
carbonate  of  lithium,  415. 
mineral-spring  waters,  416. 
paralysis  of,  due  to  diseases  of  the  nu- 
tritive and  nervous  systems,  405. 
Brain,  blood  supply  of,  74. 
Brain  and  nervous  system,  premature  de- 
velopment of,  28. 
Brains,  sexual  differences  of,  71. 
structural  differences,  male    and   fe- 
male, 76. 
Bremer,  Dr.  Ludwig,  on  neurasthenia, 
313. 

Cancer,  362. 

diagnosis,  363. 

history,  362. 

treatment,  364. 
Catheter    in    determining    haemorrhage 

from  bladder,  438. 
Central  galvanization,  107. 
Cervical  endometritis,  217. 

in  the  insane,  343. 
Chalybeate  tonics,  177. 
Characteristics  of   sex,  active  period  of 
life,  61. 

adipose  and  cellular  tissue,  68. 

anatomical,  65. 

brain  and  nervous  system,  71. 

clavicles,  67. 


522 


MEDICAL    GYXECOLOay. 


Characteristics  of  sex,  cranium,  67. 
extremities,  66. 
hair,  68. 

mammary  glands,  67. 
muscular  system,  67. 
organs  of  special  sense,  69. 
osseous  system,  65. 
pelvis,  65. 

sensitiveness  to  pain,  70. 
sympathetic  nervous  system  in  woman, 

77. 
thorax  and  abdomen,  68. 
Charcot  on  hysteria,  292. 
Childhood,  nutritive  changes  in,  6. 
Children,  diet  for,  in  health,  6. 

diet  for,  in  sickness,  9. 
CMorosis,  56. 
anatomical  character  of,  57. 
causation,  57. 
treatment,  58. 
as  a  cause  of  delayed  puberty,  56. 
Chorea,  vesical,  393. 
Clavicles  in  women.  65. 
Climate  as  affecting  menstruation,  46. 
Coffee  in  disease,  141. 
Constitutional  derangements  due  to  or 
accompanying   inflammatory   dis- 
eases of  the  sexual  organs,  248. 
Cranium  in  women,  67. 
Crichton-Browne,  Sir  James,  on  sexual 

differences  of  brains,  71. 
Crowell,  Dr.,  sections  by,  515. 
Gushing.  Dr.,  on  abscess  of  the  rectum, 

424. 
Cystic  tumors,  169. 
Cystitis,  441. 

causation,  452. 
diagnosis,  449. 
diet,  in,  459. 
definition,  441. 
pathology,  442. 
symptomatology,  444. 
treatment,  458. 
Cystorrhagia,  436. 
causation,  438. 
characteristics,  437. 
determining  source  of  haemorrhage  by 

catheter,  438. 
symptomatology,  437. 
treatment,  439. 

Dewees.  Dr..  on  the  center  of  gravity  of 
the  body,  245. 


Diamorphism,  sexual,  18. 
Diarrhoea  in  aged  women,  487. 

pathology,  487. 

treatment,  488. 
Diathesis,  diabetic,  161. 

fibroid,  162. 

gouty,  161. 

hsemorrhagic,  161. 

neuropathic,  161. 

psychotic,  161. 

rheumatic,  161. 

strumous,  161. 

tuberculous,  162. 
Dickenson,   E.  L.,  M.  D.,   on  prolapsus 

uteri  from  tight  lacing,  14. 
Diet  in  disease  and  therapeutics,  140, 

alcohol,  141. 

coffee  and  tea,  141. 

Debove's  "  alimentation  forcee,"  144. 

foods  to  be  omitted,  145. 

forced  feeding,  143. 

in  acute  cases,  143. 

malt  extracts,  143. 

milk,  142. 

pancreatin,  143. 

pepsin,  143. 

spai'e  diet,  144. 

vegetable  diet,  144. 
for  aged  women,  146. 
for  children,  6. 
for  unhealthy  children,  9. 

water,  140. 
Differentiation  of  sex  at  birth,  1. 

at  puberty,  16. 

heredity  in,  1. 
Diseases  of  the  external  genitals,  255. 

of  old  age,  468. 
Displacements  of  uterus,  234. 
Distilled  water,  140. 
Drink  for  children,  8. 
Dudley,  Dr.  A.  Palmer,  on  varicocele,  511. 
Dubois's  experiments,  381. 
Dynamic  electricity,  117. 
Dysmenorrhoea,  53. 

in  insanity,  322. 

Education,  aim  of,  32. 

Eggs,  as  food  for  the  sick,  142. 

Electric  current  in  paralysis  of  bladder, 

407. 
Electricity,  general  consideration  of,  in 

the    therapeutics  of    gynecology, 

107. 


INDEX. 


52? 


Electricity,  central  galvanization,  107. 
description  of,  107. 
faradization,  111. 

manner  of  operating,  113. 
where  indicated,  114. 
franklinization  or  static  electricity,  115. 
high  voltage,  primary  or  mixed  cur- 
rent, 120. 
treatment  by  shock,  116. 
by  spark,  115. 
Engelmann  coil,  123. 
general  law,  125. 
Electrology,  149. 
Emmet,  Dr.,  on  menstrual  derangements 

as  a  cause  of  sterility,  19. 
Emotions,  undue  cultivation  of,  30. 
Endometritis,  211. 
causation,  216. 
history  of,  212. 
pathology,  213. 
symptomatology,  215. 
treatment,  218. 
Endometritis  polyposa,  343. 
Endometrium  as  affected  by  menstrua- 
tion, 38. 
Enlarged  kidneys,  167. 
Environment   in    developing    secondary 

sexual  characteristics,  93. 
Epigastric  region,  contents  of,  165. 
Erotomania   following    the  menopause, 

327. 
External  genitals,  diseases  of,  255. 
Extremities  in  woman,  66. 

Fairchild's  essence  of  pepsin,  144. 

Faith  cure,  153. 

Faradization,  111. 

Ferguson,  Dr.  Frank,  on  carcinoma,  356. 

Ferrier  motor,  area  of,  73. 

Fibroid  diathesis,  162. 

Fibromata,  uterine,  358. 

Figures,  81,  117,  121,  123,  128,  129,  130, 

131,  165,  235,  237,  242,  245,  246, 

247,  513,  514,  515. 
Ifoods  to  be  omitted  in  acute  diseases, 

145. 
Forced  feeding,  143. 
Forbes's  diastase,  144. 
Fothergill  on  ovarian  dyspepsia,  426. 
Franklinization  or  static  electricity,  115. 
Frequent  and  difficult  urination,  390. 
Fritseh  on  senile  endometritis,  489. 
Function  of  the  bladder,  378. 
34 


Functional  characteristics  of  sex,  79. 

diseases  of  the  bladder,  384. 

diseases  of  the  nervous  system  asso- 
ciated with  diseases  cf  the  sexual 
organs,  274. 

Galaetorrhoea,  353. 

Galvanic  battery,  121. 

Girls,  anatomy  and  physiology  for,  33. 

mental  education  of,  28. 
Gonorrhoea  as  a  cause  of  acute  urethritis, 

466. 
Gouty  diathesis,  161. 
Gummata  of  liver,  166. 
Gynecology,  therapeutic. agents  employed 
in  the  practice  of,  100. 

Heemorrhage  from  the  bladder,  436. 
Haemorrhagic  diathesis,  161. 
Hsemorrhoidal  tumors  and  fissures  in  old 

age,  486. 
Hair  in  women,  68. 
Healthy    parentage    a    prerequisite     of 

healthy  progeny,  2. 
Hegar's  experiments,  381. 
Heredity  in  differentiation  of  sex,  1. 
Hermaphroditism,  17. 
High  voltage,  primary  or  mixed  current, 

120.^ 

Holden  on  tumors,  267. 

Home  culture,  26. 

Hydrotherapy,  100. 

effects  of,  101. 

in  treatment  of  neurasthenia  and  nerv- 
ous affections,  101. 
manner  of  treatment,  102. 
Turkish  bath,  103. 

in  cases  of  hysteria,  104. 
dangers  of,  from  contagion,  105. 
Hygiene,   clothing,   food,   and    environ- 
ment during  early  life,  2. 
Ilypersemia,  434. 
acute,  435. 
passive,  435. 
causes,  436. 
diagnosis,  436. 
treatment,  436. 
Hyperassthesia  of  the  vulva,  265. 

vesical,  391. 
Hypnotism.   See  Mental  Therapeutics, 
148. 
in  hysteria,  302. 
Hypochondriac  regions,  contents  of,  165. 


524 


MEDICAL   GYNECOLOGY. 


Hypogastric  region,  contents  of,  169. 
Hysteria,  285. 

causation,  293. 

diagnosis,  292. 

illustrative  case,  302. 

pathology,  286. 

prognosis,  292. 

treatment,  295. 
hysterical  paroxysms,  302. 

Iced  water,  use  of,  8. 

Iliac  region,  contents  of,  169. 

Illustrative  cases,  baruria,  418. 

bladder,  functional  derangements  of, 

416. 
bladder,  paralysis  of,  409. 
hysteria,  302. 

mammary    glands,    areolar    hyper- 
plasia of,  355. 
mammary  glands,  occasional  swell- 
ing of,  351. 
muscular  exercise,  128. 
opium  habit,  373. 
prolapsus  and  retroversion,  245. 
pruritus  of  vulva,  264. 
senile  endometritis,  486. 
sexual  pervei'sion,  327. 
Imperfect  development,  origin  of,  30. 
Incontinence  of  urine,  392. 
Inflammation  of  the  bladder,  441. 
Fallopian  tube,  231. 
lining  membrane  of  uterus,  211. 
ovary,  224. 
pelvic  organs,  199. 
urethra,  466. 
uterus,  211. 
vagina,  268. 
vulva,  256. 
Insanity.    See  Sex  in  its  Relation  to, 

315. 
Insane  sexual  desires,  335. 
Intellectual  and  moral  characteristics  of 

woman,  79. 
Intestines  and  omentum,   prolapsus  of, 

505. 

Introspection,  281. 

causation,  282. 

definition,  281. 

treatment,  283. 

Invalid  habit,  369. 


Jenner,  Sir  William,  on 
143. 


]uices. 


Johnson,  Dr.  George,  on  milk  diet,  459. 
Johnstone,  Arthur  W.,  M.  D.,  on  cause 
of  carcinoma,  364. 

Keith's  mixture,  208. 

Kelp,    Dr.,    Le    Mouvement    Medicale, 

395. 
Kidneys,  enlarged,  167. 
Kupressow's  experiments,  379. 

Ledlin,  J.  H.,  M.  D.,  on  lime  water  as  a 
solvent  of  blood-clots,  439. 

Life,  active  period  of,  61. 

Lister's  boric  ointment,  262. 

Liver,  gummata  of,  166. 

Local  enlargements,  166. 

Lombroso,  Prof.  Csesar,  on  sensory  ob- 
tuseness  in  women,  70. 

Lowenfeld  on  neurasthenia,  304. 

Lubbock,  Sir  John,  on  the  brains  of  ants, 
72. 

Lumbar  region,  contents  of,  167. 

Malaria,  effect  on  urinary  organs,  401. 
Malt  extracts,  143. 
Mammary  glands,  affections  of,  348. 
anomalies  of  development,  348. 
areolar  hyperplasia  of  the,  355. 
illustrative  cases,  355. 
treatment,  356. 
delayed    and  imperfect  development, 

349. 
characteristics,  67. 
galaetorrhoea,  353. 
mastodynia,  neuralgia  of,  354. 

treatment,  355. 
occasional  swellings,  351. 
illustrative  eases,  351. 
treatment,  351. 
retracted  nipples,  350. 
treatment,  350. 
Management  of  diseases  of  women  iu 
institutions  designed  for  that  pur- 
pose, 155. 
of  unhealthy  girls,  9. 
Martin,  Sydney,  M.  D.,  blood  supply  of 

brain,  74. 
Massage,  135. 

Brandt's  method,  137. 
in  prolapsus  uteri,  137. 
mode  of  operating,  138. 
therapeutic  effects  of,  136. 
Matteson,  Dr.,  on  drug  habits,  374. 


INDEX. 


525 


Menopause,  natural  history  of,  468. 
delayed,  477. 
causation,  477. 
treatment,  478. 
enforced,  475. 

characteristics,  475. 
treatment,  476. 
premature,  472. 
symptoms,  473. 
treatment,  474. 
Menorrhagia,  179. 
Menstruation,  35. 
anatomical  characteristics  of,  38. 
conditions  necessary  to  normal,  39. 
derangements  of,  42. 
derangements  from  nervous  exhaustion 
following  prolonged  lactation,  185. 
history  of,  185. 
causation,  186. 
treatment,  187. 
from  chronic  malnutrition,  172. 
causation,  173. 
treatment,  173. 
from  defective  innervation,  179. 
causation,  180. 
history,  179. 
treatment,  173. 
from  impaired  digestion,  assimilation, 
and  imperfect  elimination,  175. 
amenorrhoea  from,  175. 
diagnosis,  176. 
treatment,  176. 
from  imperfect  development,  19. 
from  maldevelopment,  42. 
from  malformation  of  the  ovaries,  49. 
from  malformation  of  uterus,  50. 
causation,  51. 
treatment,  51. 
from  malnutrition  of  the  nervous  sys- 
tem, 182. 
causation,  183. 
treatment,  184. 
from  nutritive  system,  disorders  of,  171. 
causation,  171. 
treatment,  172. 
Menstruation  as  affecting  sexual  desire, 

82. 
Menstruation,  ovulation  as  a  cause  of,  35. 
imperfect  menstruation  from  incom- 
plete development  of  the  uterus, 
53. 
causation,  54. 
treatment,  54. 


Menstruation,  premature,  42. 
definition  of,  42. 
history,  42. 
Menstruation  nerve,  36. 
Mensuration  of  the  body,  164. 
Mental  depression,  275. 
Mental  education  of  girls,  31. 
^Mental  occupation  of  children,  28. 
Mental  power  in  old  age,  483. 
Mental  therapeutics,  hypnotics,  148. 
explanation  of,  149. 
faith  cure,  153. 
hypnotic  sleep,  150. 
Mesmer's  method  of  inducing,  150. 
therapeutic  value  of  hypnotism,  151. 
Method  of  examining  patients,  159. 
Metritis,  211. 

M.  Eugene  Monod  on  cystitis,  456. 
Middle  life,  transitions  from,  to  old  age, 

468. 
Milk  in  disease,  142. 
Mineral  water,  use  of,  140. 
Mitchell's,  Weir,  rest  cure,  280. 
Modifications  of    diseases    of   old    age, 
484. 
dyspepsia  and  constipation,  484. 
hsemorrhoidal  tumors  and  fissures,  486. 
causation,  486. 
treatment,  486. 
sacculated  rectum,  485. 
Morbid  irritability,  275. 

treatment,  276. 
Morbid  sexual  appetence,  194. 

treatment,  195. 
Morton,  W.  I.,  M.  D.,  on  static  induction 

current,  116. 
Mosher,  Dr.,  on  asymmetry,  15. 
Motor  area  of  Perrier,  73. 
Mulheron,  J.  J.,  M.  D.,  on  use  of  Euca- 
lyptus globules  in  cystitis,  461. 
Muscular  system  in  women,  67. 
Muscular  exercise,  127. 
illustrations  of,  128. 
for  amenorrhoea,  131. 
for  metrorrhagia,  132. 
Swedish  movements,  134, 

Natural  and  sexual  selection,  92. 
Neck  of  the  bladder,  neuralgia  of,  386. 
Nervous  disturbances,  252. 

treatment  of,  252. 
Nervous  dyspepsia,  250. 

treatment,  250. 


526 


MEDICAL  GYNECOLOGY. 


Nervous  oppression,  277. 

causation,  379. 

history,  277. 

symptoms,  278. 

treatment,  279, 
Neuralgia  of  the  mammary  glands,  354. 
Neurasthenia,  304. 

causation,  309. 

diagnosis,  308. 

history,  308. 

symptoms,  305. 

treatment,  310. 
Neuropathic  diathesis,  161. 
Nitrous-oxide  gas,  339. 
Noeggerath,  Dr.  E.,  on  vascular  changes 

in  ovaritis.  226. 
Nutritive  changes  in  childhood,  6. 

Odelbrecht's  experiments,  381. 

Opium  habit,  371. 

Organic  diseases  of  the  bladder,  434. 

Organs  of  special  senses,  69. 

Osier,  Prof.  William,  on  old  age,  483. 

Osseous  system  in  woman,  65. 

Ough.  Dr..  on  numerical  relations  of  the 

sexes,  97. 
Ovarian  dyspepsia,  Fothergill  on,  426. 
Ovarian  hyperfemia,  220. 

causation,  223. 

pathology,  220. 

physical  signs,  222. 

prognosis,  223. 

symptomatology,  221. 

treatment,  224. 
Ovaries  as  determining  properties  of  mind 

and  body,  17. 
Ovaritis,  224. 

causation,  228. 

history,  226. 

pathology,  225. 

physical  signs,  227. 

prognosis,  228. 

treatment,  229. 
Ovulae  Nabothii,  214. 
Ovulation  as  a  cause  of  menstruation,  35. 

Pampinocele,  513. 
Pancreatic  tumors,  166. 
Pancreatin  in  disease,  143. 
Paralysis  of  bladder,  410. 
Pelvic  organs,  acute  inflammatory  affec- 
tions of,  199. 
causation,  205. 


Pelvic  organs,  acute  inflammatory  affec- 
tions   of,    general    pathology    of, 
201. 
physical  signs,  204. 
symptomatology,  202. 
treatment,  205. 
prolapsus  of,  505. 
senile  prolapsus  of,  508. 
Pelvis  in  woman,  65. 
Pelvis,  varicose  veins  of,  511. 
Pepsin,  143. 
Peptonized  foods,  143. 
Percussion  in  massage,  136. 
Pfliiger,  laws  of  contraction,  111, 
Physical  culture.  19. 
Prayer  as  a  therapeutic  agent,  154. 
Premature  development  of  the  brain  and 

nervous  system,  28. 
Premature  development   of    the  sexual 
organs,  48. 
causes  of,  48. 
treatment  of,  49. 
excitation  of  sexual  function,  189. 
puberty,  44. 
Prepuce,  attention  to  the,  256. 
Pruritus  of  the  vulva,  260. 
Psychotic  diatheses,  161. 
Prolapsus  and  retroversion  of  the  uterus, 
239. 
of  the  abdominal  viscera  and  pelvic 

organs,  505. 
of  the  intestines  and  omentum,  505. 
causation,  506. 
pathology,  505. 
physical  signs,  505, 
symptoms,  505. 
treatment,  507. 
Trendelenburg  position,  507. 
Puberty,  retarded  or  delayed,  45. 
delayed  from  chlorosis,  56. 
with  partial  development  of  the  sexual 

organs,  46. 
causation  of,  46. 
Pure  air,  necessity  of,  10. 

Reproduction,  history  of,  2. 
Retention  of  urine,  401. 

treatment,  401. 
Rheumatic  diathesis,  161. 
Ringer.  Sidney,  on  the  use  of  tincture  of 

cantharides  in  cystitis,  460. 
Roberts.  Sir  William,  on  peptonized  milk, 
143. 


INDEX. 


527 


Rutenburg,  Dr.,  on  opening  the  bladder 
in  case  of  paralysis,  409. 

Sacculated  rectum  in  old  age,  485. 
Salpingitis,  231. 

Savage,  Dr.,  on  mental  troubles  in  meno- 
pause, 473. 
Schaick,  Dr.  G.  G.  Van,  drawings  by,  515. 
Schultz's  experiments,  381. 
Secondary  differentiation  of  sex,  16. 
Segur,  Dr.  B.  A.,  on  the  use  of  salicylate 

of  soda  in  purulent  cystitis,  462. 
Senile  endometritis,  489. 
causation,  492. 
illustrative  case,  489. 
pathology,  490. 
physical  signs,  495. 
symptomatology,  494. 
treatment,  497. 
Dr.  Edebohls,   hysterectomy   in   com- 
plete prolapsus,  502. 
Maurel,  experiments  of,  on  leucocytes, 

499. 
McKesson  and  Robbins's  pyrozone,  502. 
prolapsus  of  the  pelvic  organs,  508. 
causation,  509. 
Peaslee's  ring,  510. 
physical  signs,  509. 
symptomatology,  508. 
treatment,  509. 
vulvitis  and  vaginitis,  503. 
causation,  503. 
symptoms,  503. 
treatment,  504. 
Sensitiveness  to  pain  in  women,  70. 
Sex,  differentiation  of,  at  birth,  1. 
at  puberty,  16. 
environment  in  developing  secondary 

characteristics  of,  93. 
heredity  in,  1. 

mental  charactei'istics  of,  80. 
natui'al  and  sexual  selection,  92. 
peculiarities  in  the   diseases  growing 

out  of  characteristics  of,  97. 
in  its  relation  to  insanity,  315. 

cases  illustrative  of,  317. 
conditions    predisposing    to    insanity, 
320. 
child-bearing  and  lactation,  323. 
dysmenorrhoea,  322. 
menopause,  327. 
Sexual  continence  as  a  cause  of  disease, 
390. 


Sexual  dimorphism,  18. 
differences  of  brains,  71. 
frigidity,  or  sexual  ana3sthesia,  196. 
causes  of,  197. 
rule  to  be  followed,  197. 
function,  derangements  of,  189. 
causation,  190. 
natural  or  unnatural  exercise  of,  192. 
diagnosis,  193. 
symptoms,  192. 
ti'eatment,  194. 
premature  development  of,  48. 
starvation  of,  195. 
treatment,  196. 
organs,  diagnosis  of  diseases  of,  in  the 
insane,  337. 
palpation,  341. 
physical  signs,  341. 
cervical  endometritis,  343. 
endometritis  polyposa,  343. 
ovarian  disease,  341. 
treatment,  343. 
perversion,  326. 
Shaw,  Dr.,  on  use  of  nitrous-oxide  gas  in 

treatment  of  the  insane,  315. 
Sims,  Marion,  on  vaginismus,  425. 
Solid  tumors  of  the  abdomen,  170. 
Spare  diet,  144. 

Squibb's,  Dr.,  fluid  extract  of  ergot,  360. 
Static  electricity,  or  franklinization,  115. 
Structural  differences,  male  and  female 

brains,  76. 
Strumous  diathesis,  162. 
Suggestion  in  hypnotism,  150. 
Suggestive  therapeutics,  276. 
Supernumerary  mammary  glands,  349. 
Sympathetic  nervous  system  in  women, 

77. 
Syphilis  as  related  to  menstruation,  173. 

Tea  in  disease,  141. 
Telepathy,  150. 
Temperaments,  23. 

Thompson.  Sir  Henry,  method  of  exam- 
ining the  urine,  450. 
Tight  lacing,  injuries  resulting  from,  13. 
Thorax  and  abdomen  in  women,  68. 
Tuberculous  diathesis,  162. 
Turkish  bath  in  cases  of  hysteria,  104. 
Tyndall's  prayer  test,  154. 

Uncomplicated  vulvitis,  256. 
Unnatural  habits,  369. 


628 


MEDICAL  GYNECOLOGY. 


Unnatural  habits,  invalid  habit,  369. 
history,  369. 
treatment,  370. 
opium  habit,  371. 

medical  treatment  inducing  the  habit, 
372. 
illustrative  cases,  373. 
diagnosis,  374. 
treatment,  375. 
Urethra,  functional  diseases  of,  463. 
neuralgia  of,  463. 
history,  463. 
illustrative  case,  464. 
treatment,  465. 
Urethritis,  466. 
acute.  466. 

gonorrhoea  as  a  cause  of,  466. 
treatment,  467. 
Urethro-vesical  neuroses,  386. 
Urinary  organs,  diseases  of,  378. 
hygiene  of,  382. 

derangements  of,   from   diseases  of 
other  pelvic  organs.  424. 
Urine,  incontinence  of,  392. 

retention  of,  401. 
Uterine  enlargements,  169. 
fibromata,  358. 
history,  358. 
treatment,  359. 
Uterus,  234. 

anatomy  of,  235. 
displacements  of,  234. 
prolapsus  and  retroversion,  239. 
causation,  242. 
illustrations  of,  245. 
pathology,  239. 
symptomatology,  241. 
treatment,  244. 

Vaginitis,  268. 

causation,  271. 
history.  268. 
pathology,  269, 
physical  signs,  270. 
prognosis,  271. 
symptomatology,  270. 
treatment,  271. 
Engelmann's  method,  272. 
in  acute  eases,  272. 
Van  Buren  and  Keyes,  tripod  treatment, 

420. 
Varicose  veins  of  pelvis,  511. 
history,  511. 


Varicose  veins  of  pelvis,  history,  Barnes, 
Kolb,  and  Brandt,  511. 
Dr.  Dwight,  511. 
Dr.  A.  Palmer  Dudley,  511. 
Dr.  Crowell,  515. 
Dr.  George  G.  Van  Sehaick,  515. 
causation,  517. 
diagnosis,  516. 
physical  signs,  516. 
symptoms,  515. 
treatment.  517. 
Dr.  Dudley,  removal  of  veins.  518. 
Dr.  Engelmann,  use  of  electricity  in, 

519. 
Prof.  Corydon  L.  Ford,  511. 
Prof.  Porter,  drav?ings  from  micro- 
scopical examination,  513. 
Vegetable  diet  in  disease,  144. 
Vesical  chorea,  393. 
hypera3sthesia,  391. 
tenesmus  caused  by  malaria,  422. 
Vin  Nourry  lodotane,  174. 
Virchow     on     ovaries     as     determining 
properties  of  mind  and  body, 
17. 
Vulva,  diseases  of  the,  256. 
hyper^esthesia  of  the,  265. 
causation,  266. 
diagnosis,  265. 
history,  265. 
treatment,  266. 
pruritus  of,  260. 
causation,  261. 
illustrative  case,  264. 
pathology,  260. 
physical  signs,  261. 
symptomatology,  261. 
treatment,  262. 
varicose  veins  of  the,  266, 
causation,  266. 
physical  signs,  266. 
symptomatology,  267. 
treatment,  267. 
Vulvitis,  256. 

causation,  257. 
diagnosis,  257. 
history  of,  256. 
physical  signs,  257. 
symptomatology,  257. 
treatment,  258. 

Water,  necessity  of  its  being  pure,  140. 
distilled,  140. 


INDEX. 


529 


Weber,  Prof.  Max,  on  sexual  dimor- 
phism, 18. 

Whey,  therapeutic  value  of,  142. 

Williams,  Dr.,  on  the  mucous  membrane 
in  menstruation,  39. 

Winckel,  Dr.,  on  electricity  in  paralysis 
of  the  bladder,  407. 

Witte  and  Rosenthal  on  closure  of  the 
bladder,  379. 

Woman,  function  in  life,  84. 


Woman,  intellect  and  morals,  79. 
in  learned  professions,  89. 
as  musicians,  86. 
osseous  system  of,  65. 
peculiarities  in  the  diseases  of,  growing 

out  of  sexual  characteristics,  97. 
perceptive  faculty,  intuition,  passive- 

ness,  and  dependence  of,  80. 
sexual  instincts  of,  82. 
sympathetic  and  nervous  system,  77. 


THE   END, 


January,   1895. 

MEDICAL 


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8 

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VOGEL  (A.).  A  Practical  Treatise  on  the  Diseases  of  Children.  Translated 
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WALTOX  (GEORGE  E.j.  Mineral  Springs  of  the  United  States  and  Canadas. 
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WEEKS-SHAW  (CLARA  S.).     A  Text-Book  of  Nursing.     For  the  Use   of 

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WELLS  (T.  SPEXCER).    Diseases  of  the  Ovaries.     Bvo.     Cloth,  $4.50. 

WORCESTER  (A.).     Monthly  Xursing.     Second  edition,  revised.     Cloth,  $1.25. 

WYETH  (JOHX  A.}.  A  Text-Book  on  Surgery :  General,  Operative,  and  Me- 
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